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YOUR future job as an Emergency Medical Technician entails that you think like a detective. You must be good in asking questions, listening to answers, and making quick decisions. In short, you must be a good problem solver.

Of course you are not supposed to take things at face value. You have to treat every case as a puzzle, and, just like Sherlock Holmes, try to put the pieces together in your mind, get the real picture, and provide treatment appropriately.

Yet this is not guesswork. Critical thinking is actually a formal process. Medical doctors in hospitals have a way of reaching conclusions. And as a future EMT, you, too must have a set of predefined steps in how to make decisions.

You may ask: Why is a formal critical thinking process important?

Personal experience and beliefs such as prejudices, stereotypes, oversimplifications, generalizations, illusions, delusions and rationalizations can affect the way we interpret information as well as the decisions we make. This occurs in the subconscious and we don’t realize it’s occurring. A formal critical thinking process helps you to identify these mindsets so we may make better decisions.

In this chapter, you would be taught the basics of critical thinking. It is our desire to help develop a thoughtful yet quick process in your decision-making that would translate to better care for your future patients.

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Critical Thinking and Decision Making Traditional Approach to Medicine How EMTs Diagnose Communication and Documentation Special Issues and Situations

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CRITICAL THINKING AND DECISION MAKING LEARNING OBJECTIVES • Define the components, stages, and sequences of the critical thinking process and apply the fundamental elements.

• Differentiate among critical life-threatening, potentially lifethreatening, and non-life-threatening patient presentations.

• Develop strategies for effective thinking under pressure.

Sa chapter na ito ay matututunan mo ang mga hakbang na ginagamit sa critical thinking process, o ang proseso kung papaano nagdedesisyon ang isang EMT. Katulad ng isang doktor, kailangan gumawa ng pagsusuri ang isang EMT at maglabas ng kanyang “diagnosis” base sa kanyang nakita, narinig, nahawakan, at dati nang kaalaman.

At kailangan niya itong gawin nang mabilisan.

INTRODUCTION

In the medical practice, there was once a time when the phrase“EMTs don’t diagnose” was widely accepted. But in reality, there are conditions that EMTs have to diagnose, such as in cases of cardiac arrest. There are also conditions that EMTs don’t diagnose, like in the case of tetanus.

However, emergency physicians don’t typically make the diagnosis of tetanus, either. What’s the difference between the diagnosis an EMT makes and the diagnosis other health care providers make?

Cardiac arrest is at one end of the spectrum of diagnoses that stretches all the way from minor conditions like a cut finger to liver lacerations and lung cancer and beyond. EMTs learn enough to diagnose a few things, although the their conclusion may be a very generalized

diagnosis. For example, an EMT may say that a patient has abdominal pain of unknown cause. Although this sounds vague, it is the same diagnosis emergency physicians may use when, after both laboratory and radiologic testing, the cause of a patient’s abdominal pain still cannot be determined. The emergency physician has the training, experience, and resources to rule out and diagnose many more causes of abdominal pain than an EMT does. For that reason, the emergency physician’s diagnosis is more specific.

Nonetheless, there are some similarities between how EMTs function in the field and how emergency physicians function. Obviously, as an EMT with very limited training, you are not expected to have the same depth of knowledge or expertise in diagnosis ..as a physician with thousands of hours of classroom and clinical training.

EMT DIAGNOSIS AND CRITICAL THINKING An EMT’s diagnosis is a description or label for a patient’s condition, based on the patients history, physical exam, and vital signs, that assists the EMT in further evaluation and treatment. It may be referred to by other names: EMS diagnosis, EMT diagnosis, field diagnosis, presumptive diagnosis, or working diagnosis. Regardless of 246

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the name, they all refer to how EMTs come to a conclusion, after assessing a patient, about the nature of the patient’s condition (or sometimes what it is not). The process of reaching a diagnosis involves a great deal of simultaneous activity, both physical and intellectual. It is sometimes difficult to determine in the field how much information to

NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe.

Used with permission from Pearson Education, the publisher of the book.

get and when to get it. The process that assists the EMT in doing this is called critical thinking There are many descriptions of critical thinking. It is an analytical process that can help someone think through a problem in an organized and efficient manner. It is also thinking that is reflective, reasonable, and focused on deciding what to do in a particular situation. Some people describe it as an attitude of inquiry that involves the use of facts, principles, theories and other pieces of information.

All of these descriptions contain some truth. However, this chapter is going to focus primarily on critical thinking as an analytical process that can help someone think through a problem in an organized and efficient manner.

HOW A CLINICIAN REACHES A DIAGNOSIS Different clinicians have different levels of training and experience, time, technology, and other resources. Despite all of these differences, they all have to reach some kind of conclusion about what is wrong with the patient and what kind of treatment to administer. All clinicians begin with the same basic approach – gather information, consider possibilities, and reach a conclusion.

The way they implement these steps, however, varies significantly.

The Traditional Approach to Diagnosis in Medicine The first step in the traditional approach to diagnosis is assessing the patient. Next, the clinician draws up a list of conditions or diagnoses that could be causing the patient’s condition. This list is called a differential diagnosis or just the “differential.” To determine which of the potential diagnoses is correct, the patient receives further evaluation and perhaps some tests to rule in or rule out the diagnoses on the list. Once the results of the assessment and tests are known, the clinician considers those results and excludes conditions that are unlikely to be correct. In the end. this results in a diagnosis or, in some cases, a few possible diagnoses). Sometimes, as a result of the additional assessment, the list becomes longer before it can be narrowed down.

For example, suppose an EMT is assessing a patient with abdominal pain. He does a primary assessment, gathers the history of the present illness and past medical history, performs a pertinent physical exam, and institutes treatment and transport. After completing all of these steps, the EMT still is unsure of what is causing the patient’s condition. The patient might have an abdominal aortic aneurysm, pancreatitis, gallstones, a duodenal ulcer, or any of a variety of other conditions. Although a physician may be able to diagnose many of these specific conditions, that ability usually requires a significant amount of training, experience, clinical skill, laboratory tests, imaging, and perhaps even consultation with a specialist. How would a clinician determine what is wrong with this patient?

The Emergency Medicine Approach to Diagnosis The emergency physician often does not have the time or the resources to use the traditional approach to reach a diagnosis. Instead, because of the unique circumstances and environment of the emergency department, his goals are ruling out life-threatening conditions, narrowing the range of possible diagnoses, and instituting urgent treatment. Part of the treatment may often be referral to the patient’s own physician or a specialist to conduct further evaluation once the emergency physician determines that the patient’s condition does not require admission to the hospital.

The first step in the Emergency Room, therefore, is to quickly rule out or identify and treat immediate life threats. Once that is done, the physician gathers information from the patient, family, and friends and performs a physical exam. The focus of much of the questioning and assessment is to rule out the worst-case scenarios (i.e. the conditions that may threaten the patient’s life or quality of life later on). The emergency physician looks for red flags, which are signs or symptoms that suggest the possibility of a particular problem that is very serious. For example, sudden onset of tearing pain in the abdomen that radiates to the back is a red flag that suggests an abdominal aortic aneurysm.

The information obtained from the secondary assessment guides the clinician in formulating a differential diagnosis, leading him to ask further questions and order particular tests. However, not every test is available to the physician in the Emergency Department. A patient with a 4-week-old knee injury will probably have to wait to get an MRI (magnetic resonance imaging) to see what is going on inside the joint.

The emergency physician is therefore working with less information than the physician in an office environment. Once additional information is available from the laboratory and other tests, the physician considers it and comes to a diagnosis and disposition. The diagnosis may be very specific, like appendicitis, or it may be as general as abdominal pain of unknown cause.

All of this occurs in the busy, hectic environment of the Emergency Room, where the physician may be caring for four or five (or more) patients simultaneously and is frequently being interrupted with additional information or questions.

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The EMS Approach to Diagnosis The EMT has a lot in common with the emergency physician. He has limited resources available, has few treatment options (although those he does have are very important), and knows time is of the essence. Unlike the emergency physician, however, the EMT cannot usually care for four or five patients simultaneously. Since the EMT has to go to the patient, the EMT is unavailable for other patients until that first patient has been delivered to another clinician. This puts pressure on the EMT to be very efficient; the sooner he completes his duties with one patient, the sooner he can get to the next. The EMT also works in an uncontrolled environment. For example, the emergency physician does not usually have to worry about being bitten by a patient’s dog. However, emergency physicians do occasionally encounter violent patients in the Emergency Department. just as the EMT docs in the field.

The tools the EMT has available in the field differ, too.

Although the amount of technology used in the field has increased tremendously over the last 10 to 20 years, EMTs have nowhere near the resources available in an Emergency Department. An EMT can merely evaluate a patient’s vital signs and oxygen level of the blood, whereas the emergency physician can order multiple blood tests and imaging studies like Xrays, ultrasound, and CT (computed tomography) scans The EMT’s education focuses narrowly on certain conditions that have high statistical morbidity (illness) or mortality (death), whereas the emergency physician completes at least 3 years of postgraduate training after 4 years of medical school. Most important, much of that education is spent seeing thousands of patients and learning assessment and management skills under supervision.

All of this means that although the EMT will follow many of the same steps the emergency physician does in reaching

a diagnosis, most of the EMT’s diagnostic steps will be abbreviated or limited. The EMT’s primary assessment finds and treats the patient’s immediate life threats Secondary assessment—consisting of the patient’s history, physical exam, vital signs and a few tests—comes next, with special attention devoted to looking for red flags.

Simultaneously, the EMT begins treatment that may be beneficial and is not harmful. The most common example of this is administering oxygen.

The EMT then considers the most serious conditions associated with the patient’s presentation that can be treated in the Field and quickly rules them in or out, so that important treatment can be administered as quickly as possible. If the patient has no life-threatening conditions and no red flags, the EMT creates a mental list of possible causes or diagnoses (a differential diagnosis). This list will often be short e.g. in a patient with abdominal pain, the differential may be abdominal aortic aneurysm, gastrointestinal bleeding, dehydration, and all other causes of abdominal pain).

Next, depending on the situation, there may be further evaluation limited by the time and resources available in the field. This further evaluation may take place while en route to the hospital. After considering the results of any additional evaluation, the EMT may be able to narrow the list of possible diagnoses. In many cases, this may simply be a restatement of the chief complaint (e.g.. abdominal pain) as the diagnosis.

Although all three of these approaches to diagnosis— traditional, emergency medicine, and EMS—have a lot in common, some differences clearly exist.

The Highly Experienced Physician’s Approach to Diagnosis Very experienced physicians do not always use the traditional approach of drawing up an extensive list and narrowing it down. Instead, they have learned “shortcuts” (also called heuristics) that speed up the processor reaching a diagnosis. These shortcuts, based on pattern recognition, help make physicians belter, more efficient clinicians. The expert clinician can quickly recognize certain features of a patient’s presentation that significantly narrow the diagnostic possibilities. The experienced physician can also quickly determine what further evaluation is necessary to rule in or rule out certain possibilities. As a result, highly experienced physicians can reach difficult diagnoses or conclusions more quickly than newer physicians who need more time to consider the possibilities.

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clinicians understand this and keep in mind avoidable traps so that their conclusions are as accurate as possible.

As you gain experience in the medical field, you can start to develop shortcuts like experienced physicians do. In doing so, however, you will need to understand the advantages and shortcomings of shortcuts, or heuristics. Here arc some of the more common heuristics and their biases.

• Representativeness. Representativeness means that

when you encounter a patient with a certain group of signs and symptoms that resemble a particular condition, you assume the patient has that condition.

Representativeness is at the heart of pattern recognition and is an important heuristic. What is its disadvantage? Patients don’t always present with the

typical signs and symptoms of a condition. As a result, when a patient doesn’t fit the classic pattern, it’s easy for the health care provider to mistakenly conclude the patient doesn’t have that condition. For example, older patients with myocardial infarctions sometimes deny chest pain and complain instead of shortness of breath or weakness as their chief complaint. To avoid this trap, remain aware of its possibility. Remind yourself that patients don’t read the textbooks and can present with uncommon or atypical signs or symptoms. A way to summarize representativeness is to think of the saying.

“If it looks like a duck and quacks like a duck, it must be a duck—except when it isn’t.”

• Availability. Availability is the urge to think of things because they arc more easily recalled, often because of a recent exposure. For example, if an EMT has a patient with chest pain who is diagnosed with a dissecting thoracic aneurysm, the next time he sees a patient with chest pain, he is more likely to think of dissecting thoracic aneurysm as a possibility, even though the condition is much less common than angina and myocardial infarctions. Because of his recent exposure to this condition, he may overestimate its frequency. You can reduce your chances of falling into this (rap by asking yourself just how common the particular condition is that you’re considering and whether you’re considering it mainly because it matches information that is easily available. One way to think of the problem of availability is the EMTs tendency to say. “You have the same thing my last patient had!”

• Overconfidence. Being an EMT requires a significant degree of confidence. Without it, the EMT is unable to function in a chaotic environment. Overconfidence, however, can work against the EMT. Thinking you know more than you really do can lead to many problems. A good way to avoid this tendency is to be aware of the limits of your knowledge and ability. Be careful in your assessment, however, Surveys consistently show that people think they know more than they actually do.

When faced with a clinical situation, try to be as objective as possible when evaluating how much evidence has been gathered and whether it has been gathered in a logical and thorough fashion. Try to keep your ego out of this selfevaluation as much as possible. You can summarize the problem of overconfidence as, “Of course I know what to do. I’m an EMT!” • Confirmation bias. A clinician commits confirmation bias when he primarily looks for evidence that supports the diagnosis he already has in mind. By doing so. he may very well overlook evidence that refutes or reduces the probability of that diagnosis. This commonly occurs when the patient’s presentation includes a lot of information and the clinician feels it’s easier to go with one diagnosis rather than look for others. To avoid this pitfall, look for data that refutes the diagnosis you have in mind or reduces the likelihood of it. In other words, look for contrary data and consider competing hypotheses. The

tendency to look only for information that supports what you already think is reflected in the saying, “It must be right—I thought of it!”

• Illusory correlation. Human beings are able to draw conclusions about how the world works because they are able to see how one thing causes another. However, this human tendency can be misleading sometimes. Very often, one event may appear to cause another when, in fact, the two events are either coincidental or both caused by the same thing, leading 10 illusory correlation. For example, some believe that fluoridated water causes cancer. It is true that communities that have fluoridated their water have a higher rate of cancer than rural areas.

Therefore, it would be very easy to conclude that one caused the other. However, when you look more closely at the data, you discover that cities are more likely than rural areas to fluoridate their water. Cities have higher rates of cancer than rural areas in general. Furthermore, cities that fluoridate have the same incidence of cancer as cities that do not fluoridate. Therefore, the appearance of cause and effect in this case is an illusion. To avoid this illusion, be skeptical about instances where one thing appears to cause another. Consider bow the appearance of two things together may be just coincidence or, alternatively, consider that they may both have the same cause. An easy way to remember illusory correlation is to think of this: “Most ice cream is eaten during the summer. Most drownings occur in the summer.

Therefore, ice cream causes drowning.”

• Anchoring and adjustment. In this situation, an EMT considers a particular condition to be likely, and his later thinking is anchored to that hypothesis. He may adjust it in time, but sometimes not as much as he should because of his starting point. For example, an EMT may initially think that an unconscious intoxicated person is unconscious because “he’s just drunk.” When information appears that the patient may have sustained head trauma, the EMT may cling to the hypothesis that the patient’s real problem is just intoxication. To avoid this, be careful not to jump to conclusions and determine a diagnosis on the basis of just a few signs or symptoms.

Do a thorough assessment. The tendency to cling to your first conclusion is exemplified in the saying. “You only get one chance to make a first impression.”

• Search satisfying. It can be very satisfying to finally determine what is causing a patient’s problem. However, once that happens, it becomes very easy to stop looking for other causes of potential problems. This is called “search satisfying.” The problem with search satisfying is that you can miss a secondary diagnosis (many EMS patients have more than one problem) or just be mistaken in the primary diagnosis. If you don’t look for other problems, you will probably not detect them. A good way to prevent this problem is to keep an open mind about other possibilities and to evaluate each diagnosis before accepting it. This principle is well stated in the saying.

“Don’t count your chickens before they hatch.”

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HOW AN EMT CAN LEARN TO THINK LIKE AN EXPERIENCED PHYSICIAN The following list features attitudes and understandings you can develop to help you think like an expert.

• Learn to love ambiguity. This is at the core of EMS,

Working in EMS means you are going out into unknown situations armed with limited education and experience (compared to physicians and many other clinicians) and equipped with limited tools and treatments. You are expected to make decisions, including some life-or-death decisions, in a very short period of time before you transport the patient to definitive care. You will not be able to gather the same amount of information that staff does in a hospital and you have a limited range of treatments to provide your patients.

No matter how conscientious and knowledgeable you are. you will run into situations where you just can’t find a definitive answer to the question of why a patient is sick. That is the nature of EMS. By accepting that uncertainly is a natural part of what you do, you will actually become a better provider, able to understand the limitations of your knowledge and how this affects your patient care.

• Understand the limitations of technology and people.

No one is perfect. Every human being makes errors.

Some people go about procedures in ways you would never think of doing. Once you accept this, you will find it easier to work in the everyday world where things don’t always go as you planned. When you get information from someone else, whether a crew member, patient, or bystander, consider the source.

How accurate and reliable do you judge the source to be? Is there a potential source of bias that might affect the way that person reports information? Is there a limited skill level or lack of familiarity with EMS that should make you consider how to process information from someone else? Similarly, no piece of equipment is perfect. Every mechanical or electronic device is subject to failure, whether from low batteries inappropriate use. or excessive wear. When you get a reading from a device that doesn’t make sense for the clinical picture in front of you. don’t accept it as necessarily correct. If possible, have the device repeat the reading. Consider how the unexpected result could affect your management of the patient.

In the end. you may need to make a decision regarding whether to accept an anomalous reading or go with your clinical judgment. Whether you made the correct decision is often not clear until later.

• Realize that no one strategy works for everything. No matter how experienced and skilled you become, you will encounter situations that don’t work well for your particular approach to EMS calls. In cases like this, it is important to be flexible and able to use more than 250

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just a single tactic. Times like this are when experts think like new clinicians. They have to formulate a longer list than usual of differential diagnoses and rule them in or out.

• Form a strong foundation of knowledge. Expert clinicians may use different approaches to thinking through problems, but one thing they all have in common is a strong foundation of knowledge. They are extremely familiar with the signs and symptoms of conditions they are expected to be familiar with. They are also very aware of conditions that can mimic those diseases. They keep up-to-date with new information on associated conditions that sometimes accompany those diseases. They have both the tools (the thinking processes) and the supplies (the knowledge to apply those tools to).

• Reflect on what you have learned. An essential part of being an expert clinician is learning from your experiences. Contrary to popular belief, people don’t learn only from their mistakes. People learn even more from their successes. When someone succeeds in a venture, this reinforces the behavior that led to the success and leads to good habits. After a patient’s contact, especially a challenging one, evaluate your behavior. What did you do well? What can you do better.’ What did you learn that you didn’t know before? What knowledge do you need to he more accurate and efficient in the future?

• Organize the data in your head. Create what experts call elaborated knowledge. Once you can list the signs and symptoms of a disease, work in the other direction. Take signs and symptoms and consider what other diseases they may he associated with. This actually creates new connections in your brain and provides practice for what you actually will do in the field. Reflect on how the presence or severity of a particular sign or symptom changes the probability of a particular disease or condition. At first, concentrate on a few diseases that have similar chief complaints. Study them until you know the signs and symptoms of each and then work from the signs and symptoms back to the problem.

• Change the way you think. Once you have mastered the presentations of several conditions, compare and contrast them. Determine what features the conditions have in common and what features set them apart from each other. Rephrase the symptoms a patient provides so that they match more closely the way a disease is described. For instance, if a patient complains of 9/10 pain in the middle of his stomach that hit him like a thunderbolt, characterize this as the sudden onset of severe pain in the center of the abdomen.

• Learn from others. Your EMT class is only part of your

education. Take advantage of the exposure you get to expert clinicians and ask them to think out loud when they are solving problems This will familiarize you with the ways an expert looks for information processes it, and uses it to reach a diagnosis.

Keep in mind that once you have reached a possible diagnosis, your work is not necessarily over. You should continue looking for data that will help to rule in or rule out the conditions you are considering. A patient may have more than one thing wrong with him, so don’t stop looking for causes too early. Your conclusion may also be wrong, so it is good to continue thinking about what may be wrong with the patient.. These steps can be used not only with reaching an EMT diagnosis, but also with many other problems.

Being aware of how you think gives you a powerful tool

for improving your information gathering and thought processes. Keep in mind that when you are faced with an unfamiliar situation you should go back to the basics. Do your assessment and follow the general principles outlined in your EMT course.

Reaching an EMT diagnosis is a process that you can learn. However, be careful not to expect too much of yourself at the beginning—the process of thinking critically is developed through study, practice, and reflection. It will take time to develop this skill. In the meantime, don’t let anyone force you to go further than your level of competence. Know the boundaries of your knowledge, skill, and judgment. Overconfidence can be dangerous. Strive to learn more by study and observation of more experienced providers. Most important, don’t let attempts to reach a diagnosis delay patient care that is safe and appropriate.

APPROACHES TO REACHING A DIAGNOSIS TRADITIONAL APPROACH

EMERGENCY MEDICINE APPROACH

EMS APPROACH

Goal

Reach definitive diagnosis and institute treatment

Rule out life threatening conditions, narrow range of possible diagnoses, and institute urgent treatment

Rule out lifethreatening conditions, narrow range of possible diagnoses, institute treatment important to patient survival and comfort, and transport for more extensive assessment and treatment

Pace

Leisurely

Efficient

Urgent

Thoroughness

Very thorough

Focused

Limited

Assessment Tools and Tests

Wide range of tests patient can be sent for

Limited to pertinent tests that are available at the time of the patient’s presentation

A few tools pertinent to finding serious conditions quickly, like BP cuff and pulse oximeter

Extent of Patient Rapport

Significant

Limited

Limited with short transport times, greater with long transport times

Range of Possible Diagnoses

Extensive

Moderate

Limited

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FUNDAMENTALS OF EMT PRACTICE Day 10

FUNDAMENTALS OF EMT PRACTICE

COMMUNICATION AND DOCUMENTATION

COMMUNICATION AND DOCUMENTATION LEARNING OBJECTIVES

 List the correct radio procedures in the following phases of a typical call: To the scene, at the scene, to the facility, at the facility, to the station and at the station.

ng  Discuss the communication skills that shouldNapakahalaga be used to interact with the pa-

komunikasyon at mga while dokumento tient or family, bystanders, individuals from other agencies providing sa trabaho ng isang patient care and the difference between skills used to interact with the paEMT. Sa chapter na ito, tient and those used to interact with others. matututunan mo ang iba’t ibang uri ng komunikasyon  Describe the attributes for increasing effectiveness and efficiency of verbal na ginagawa ng EMT -- mula communications. sa paggamit ng radyo, pakikipag Describe what information is required inusap eachsasection ofatthe pasyente sa prehospital mga taga care List the correct in the reportradio and procedures how it should be entered. ospital. Pag-aaralan mo rin dito following phases of a typical call: To the  the Define special considerations concerning patient refusal. ang iba’t ibang report na kailangan scene, at scene,the to the facility, at the gawin ng EMT at kung bakit legal implications report. facility,to Describe the stationthe and at the station. associated with the written mahalaga ang mga ito.

Discuss the communication skills that shouldINTRODUCTION be used to interact with the patient or family, bystanders, individuals from other agencies while providing patient care and the difference between skills used to interact with the patient and those used to interact with others.

Describe the attributes for increasing effectiveness and efficiency of verbal communications.

Describe what information is required in each section of the prehospital care report and how it should be entered.

Define the special considerations concerning patient refusal.

Describe the legal implications associated with the written report.

LEARNING OBJECTIVES •

•

• • • •

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You will learn about several types of communication in this chapter; radio communication, the verbal report at the hospital, interpersonal communication, and You will learn about severalAs types communication in this chapter – radio the documentation. the of name implies, radio communication is communication, conducted by raverbal report at theTechnology hospital, interpersonal communication, documentation. the name to implies, dio. has allowed the use of celland phones and other As equipment be radio communication conducted radio.transmissions Technology has allowed the use the of cellphones and other used in isareas wherebyradio were previously only choice.

The equipment to verbal be usedreport in areas where radio transmissions were previously the only choice.

The verbal is your chance to convey information about your patient directly to report is your the chance to convey information about patient toInterpersonal the hospital personnel hospital personnel who will beyour taking overdirectly his care. communiwho will be taking overare hisimportant care. Interpersonal communications are important in dealing cations in dealing with other EMTs. the patient, familywith andother byEMTs, the patient, family and bystanders, direction, andofother members of the EMS system. standers, medical direction,medical and other members the EMS system.

Documentation is an important part of the patient care process and lasts long after the call. The report you write willDocumentation become a part of is theanpatient’s permanent record.

As records your agency, important part ofhospital the patient care processofand lasts longyour reports and those other EMTsyou become valuable source for research on trends in emergency afterwritten the callbyThe report writeawill become a part of the patient's permanent medical care and a guide for continuing education qualityyour improvementYour report may also hospital record.

As records of yourand agency, reports and those written by be used as evidence in a legal case.

Documentation has short-term benefits as well.

Noting vital signs and a other EMTs become a valuable source for research on trends in emergency medipatient’s history will help you remember important facts about the patient during the course of the cal care and a guide for continuing education and quality improvement- Yourcall. report may also be used as evidence in a legal case Documentation has shortterm benefits as well. Noting vital signs and a patient's history will help you remember important facts about the patient during the course of the call.

PREHOSPITAL EMERGENCY CARE ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

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UNIT 2 DAY 10

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COMMUNICATIONS SYSTEMS AND RADIO COMMUNICATION

COMMUNICATIONS SYSTEMS AND RADIO COMMUNICATION

Radio equipment is often taken for granted since it is now so common. However, the development of radio links between dispatchers, mobile units, and hospitals has been one of the key contributor* to improvement in EMS over the years. Imagine if you had to call the dispatcher by phone every few minutes to see if there is a call! Without radio transmissions from ambulances, hospitals would be unable to prepare for the arrival of patients, as they do now.

Radio equipment is often taken for granted since it is now so common. However, the development of radio links between dispatchers, mobile units, and hospitals has been one of the key contributor* to improvement in EMS over the years.

Imagine if you had to call the dispatcher by phone every few minutes to see if there is a call! Without radio transmissions from ambulances, hospitals would be unable to prepare for the arrival of patients, as they do now.

Communications Systems

Communications Systems

There are a number of components to any radio or There are a number of components any radio or communications base communications system: tobase stations, mobilesystem: radios, stations, mobile radios, portable radios, repeaters, cell phones, and other devices. portable radios, cell other devices.  Base nations repeaters, arc two-way radios thatphones, arc at a fixedand site such as a hospital or dispatch center.

• Base stations are two-way radios that are at a fixed site Mobile radios are two-way radios that are used or affixed in a vehicle. are actually inside the vehicle. These devices have lower such as aMost hospital ormounted dispatch center. transmitting power than base stations. The unit used to measure output • Mobile are two-way radios used power ofradios radios is the watt.

The output of a mobile that radio is are generally 20- or with a range of 10-15 miles. affixed in50 awatts vehicle.

Most are actually mounted inside the Portable radios are handheld two-way radios with an output of 1-5 watts. Thisdevices type of radio is important it will allow youpower to be in than vehicle. These have lowerbecause transmitting touch with the dispatcher, medical direction, and other members of the base stations.

The unit used output power of EMS system while you are away to frommeasure the ambulance. arc devices are usedof when transmissions must be radiosisRepeaters the watt.

The that output a mobile radio iscarried generally over a long distance. Repeaters may be in ambulances or placed in various areas around an EMS of system.

The repeater 20-50 watts with a range 10-15 miles.picks up signals from lower-power units, such as mobile and portable radios, and retransmits • Portable are The handheld two-way with an them al a radios higher power. retransmission is done onradios another freoutput ofquency.

1-5 watts.

This type of radio is important because Cell phones are phones that transmit through the air to a cell tower. In many areas thein distances or expense too great to set up a conit will allow youwhere to be touch with isthe dispatcher, medical ventional EMS radio system, cell phones allow EMS communications direction, and other members of the EMS system you through an already established commercial system. Cell phones arewhile not a solution to the problem of radio communication, however, are awayalways from the ambulance. because a cell phone needs to be able to reach a cell lower or site. As the number are of celldevices towers increases, the ability use these devices • Repeaters that are usedto when should improve. transmissions must be carried over a long distance.

Repeaters may be in ambulances or placed in various areas around an EMS system. The repeater picks up signals from lower-power units, such as mobile and portable radios, and retransmits them at a higher power. The retransmission is done on another frequency.

• Cellphones are phones that transmit through the air to a cell tower. In many areas where the distances or expense is too great to set up a conventional EMS radio ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

system, cellphones allow EMS communications through an already established commercial system. Cellphones are not always a solution to the problem of radio communication, however, because a cellphone needs to be able to reach a cell tower or site. As the number of cell towers increases, the ability to use these devices should improve.

New technologyUNIT is developing almost constantly. For 2 example, microwave radio transmissions are used in some FUNDAMENTALS OF DAY 10 areas. In others, radio communications are carried via phone lines for part of the signal’s journey from one point to another. Digital radio equipment permits transmission of some standard messages, such as technology ambulanceis developing almost constantly.

New identification or arrival at the scene, by punching key.

Theareas. In others, transmissions are useda in some ried via phone lines for helps part of the signal's journ messages are transmitted in a condensed form that Digital radio equipment permits transmission of s keep busy, frequencies less crowded. as ambulance identification or arrival at the scene

sages are transmitted in a condensed form that he

crowded.

Since radios are so important to EMS today, many systems have backup radios. This means that in the event of Since radios are so important 1o EMS today, man power failure or malfunction, another option is available.

This means that in the event of power failure or For example, if the base station available. fails, there be aifbackup For may example, the base station fails, th alternative power supply available. If the mobile radio or alternative power supply available.

If the mobile functions, portable or phones may be used radio in your ambulance malfunctions, portableradios radios or phones may be used in its place.Note that radio systems require preventive mainte

ambulance and your EMS equipment. Radio equ

care on a daily basis and not mishandled.

Note that radio systems require preventive maintenance and repair, just like the ambulance and your Radio Communication EMS equipment. Radio equipment must be treated with care on a daily basis and not mishandled.

Radio Communication

EMS is just one of many public services that use radio communication. To maintain order on the airwaves, the National Telecommunications Commission (NTC) assigns and licenses radio frequencies. This prevents two or more agencies from trying to use the same frequency and interfering with each other’s communications. There are also strict rules about interfering with emergency radio traffic and prohibiting profanities or offensive language. Some general rules for radio transmissions should always be followed. These rules prevent delays and allow all persons to use the frequencies. Although there may be some minor variations within your EMS system, always keep in mind the principles. “

EMS is ju that us maintain Nationa mission radio fre more ag same fr each ot are also with em hibiting guage.

Some g sions s These ru all persons to use the frequencies. Although there within your EMS system, a I ways 253in mind the LIFELINE PREHOSPITAL EMERGENCY CARE keep

Radio Transmissions throughout the C

The initial call Tot help received by the Emergen most often comes via telephone but may also be such as the police. After proper information is obt

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Radio Transmissions throughout the Call The initial call for help received by the Emergency Medical Dispatcher (EMD) most often comes via telephone but may also be radioed from another agency, such as the police. After proper information is obtained, the EMD dispatches the units. The following is a sample flow of information between the dispatcher and units in the field.

You are the EMT on ambulance number 6: • Dispatcher: Ambulance 6 ….

• You (Ambulance 6); Go ahead.

• Dispatcher: Ambulance 6, respond to 1243 Roxas Boulevard—that’s one-two-four- three Roxas Boulevard—for an assault. The police are en route.

Stand by at the corner of Roxas and EDSA until the police report the scene secure.

• You: Ambulance 6 received that. Will stand by at Roxas Avenue and EDSA. Without a prompt and efficient receipt and dispatch of information, the ambulance could easily be sent to the wrong location. In this situation, the dispatcher also relayed important safety information. Since the call was for an assault. The dispatcher “staged” the ambulance, or ordered it to stand by. until the scene was safe. You respond to the assigned location, reporting your arrival to the dispatcher: • You: Dispatcher. Ambulance 6 is arriving at the staging area.

• Dispatcher: Message received. Ambulance 6. I will advise you when the scene is secure Most scenes are safe. However, in this case the dispatcher has decided, from the nature of the call and other information he was able to obtain, that it is not. Police arrive at the scene and separate the parties involved in the assault.

The police radio the dispatcher and advise that the scene is secure. The next transmission is to your ambulance: • Dispatcher: Ambulance 6. the police report that the scene is secure. Respond in.

• You: Message received by Ambulance 6. (You drive two blocks lo the scene and report to the dispatcher.)

• Dispatcher, Ambulance 6 is at the scene.

• Dispatcher: Ambulance 6 at the scene (gives the time on the 24-hour clock) at 1310 hours.

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The dispatcher records all the times: the time of the original call, the time the ambulance was dispatched, the time when the ambulance reached the staging area, and finally the time when the ambulance arrived at the scene.

Should this case go to court, the records of the dispatch center, your care report, and the dispatch audio tape of the call may be subpoenaed. Unless there is a need for medical direction or assistance from the scene, the next call will be when you are en route to the hospital: • You: Dispatcher. Ambulance 6 is en route to Makati Medical Hospital with one patient.

• Dispatcher. Ambulance en route to Makati Medical Hospital at 1323 hours.

You will call the hospital via radio or phone to advise them of the status of your patient and the estimated time of arrival (ETA). When arriving at the hospital, you again advise the dispatcher • You: Ambulance 6 is arriving at Makati Medical Hospital.

• Dispatcher: Ambulance 6 at Makati Medical Hospital at 1334 hours.

You will note that the dispatcher gives the time after most transmissions. This will allow you to record times if they are required on your patient care record. The dispatcher also usually acknowledges by briefly repealing the message “ If two to ensure that he has acknowledged the right unit. units happened to transmit at exactly the same time and the dispatcher simply acknowledged a transmission, both units would think that the dispatcher heard them when, actually, only one unit was able to get through.

After turning the patient over to the hospital staff and preparing the ambulance for the next run. you will advise the dispatcher that you are leaving the hospital. You may also find it part of your local procedure to advise the dispatcher when you arc back in your district or area and when you are back in quarters (the station or ambulance garage).

A majority of these transmissions were made between the mobile radio within the ambulance and the dispatcher at a base station. Remember, when you have one available, bring your portable radio with you whenever you leave the ambulance. You may need to call for assistance during scene size-up if hazards or multiple patients are found, and the portable radio allows you to do that without running back to the ambulance to make the call on the fixed unit.

the ambulance and the dispatcher at a base station. Remember, when you have one available, bring your portable radio with you whenever you leave the ambulance. You may need to call for assistance during scene size-up if hazards or multiple patients are found, and the portable radio allows you to do that without running back 10 the ambulance to make the call on the fixed unit.

NOTE: Lifeline has a dedicated trunk radio network and uses codes in radio transmission

PRINCIPLES OF RADIO COMMUNICATION

PRINCIPLES OF RADIO COMMUNICATION Follow these principles when using the EMS Radio • Do not use phrases like “be advised.” These are System:these principles when using the EMS Radio System: implied and serve no purpose.

Follow • Make sure that your radio is on and the volume is • Courtesy is assumed,  Make sure that your radio is on and the volume is adjusted properly.so there is no need to say adjusted properly.

“Please,” “Thank you,” and “You’re welcome.”  Reduce background noisethe byvehicle closing the vehicle window whena possi• Reduce background noise by closing • When transmitting number that might be ble. window when possible. unclear (15 may sound like 16 or 50), give the • Listen to the frequency and ensure and that itensure is clear that it is clear number, thenbeginning repeat the individual digits. Say  Listen to the frequency before a beforetransmission. beginning a transmission.

“15, one-five.”

• Press the “press to talk” (PTT) button on the Anything said over the radio can be heard by  Press the "press to talk" (PTT) button on the •radio, then wait 1 second radio, then wait 1 second before speaking. This the public on a scanner. Do not use the patient’s before speaking.

This prevents cutting off the first ofFor your prevents cutting off the first few words of your namefew over words the radio. the same reason, do not transmission. transmission. use profanities or statements that tend to slander • Speak with your lipsyour about 2 to 3 inches from the Irom theany person Use objective, impartial statements.  Speak with lips about 2 to 3 inches microphone. microphone.

• Use “we” unit instead of “I.” Asoran EMT, you will  When calling another unit or base station, use their number • Whenname, calling followed another unit or base station, use rarely be acting alone. by yours. "Dispatcher, this is Ambulance 2." their unit number or name, followed by yours.

• “Affirmative” and ‘Negative” are preferred over  The unit being called2.” will signal that the transmission start the by latter are difficult to “Dispatcher, this is Ambulance “Yes” and should “No” because saying, "Co ahead" ("Ambulance 2, this is the dispatcher.

Co ahead") or • The unit being called will signal that the hear. another regionally accepted term.

If the unit you are calling tells you to about your patient, transmission should start by saying, “Go ahead” • Give assessment information "Stand 2,by,' they tell they are ready takeoffering your transmis(“Ambulance thiswait is theuntil dispatcher.

Goyou ahead”) buttoavoid a field diagnosis of the patient’s or another problem. For example, say “Patient complains sion.regionally accepted term. If the unit you are calling tells you to “Stand by,’ wait until they of chest pain” rather than “Patient is probably  Speak slowly and clearly. tell you they are ready to take your transmission. having a heart attack.”  Keep brief, If it takes longer• than seconds, stop at Wait for • Speak slowly the and transmissions clearly.

After30 transmitting, say “Over.” that point and pause for a few seconds so that emergency traffic can • Keep the transmissions brief, If it takes longer acknowledgment that the person to whom you use the frequency necessary. than 30 seconds, stop at thatif point and pause for a were speaking heard your message. few so that emergency traffic can use the • Avoid slang or abbreviations that are not  seconds Use plain English.

Avoid codes. frequency necessary. authorized.  Do ifnot use phrases like "be advised." These are implied and serve no • Use plain English. Avoid codes. Unless in your • Use EMS frequencies only for authorized EMS purpose. protocol communication.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

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LIFELINE AMBULANCE CODE SHEET

CODE

TRANSLATION

PROCEDURE CODE

TRANSLATION

Emergency situation needing immediate assistance (accident, hold up, heart attack)

OVER

Response Needed

OUT

Transmission Ended

CENTRAL

Lifeline Office

CORRECTION

Error in Transmission

MOBILE ONE

Lifeline L-200 pick up

REPEAT

Repeat Message

MOBILE TWO

Lifeline Motorcycle

ROGER

Understood

CODE 88

Your Office

AFFIRMATIVE

Yes

CODE 8-0

Secretary

NEGATIVE

No

CODE 44

Your House

DO YOU COPY

Do you understand?

CODE 4-0

Your Spouse (or any household member)

THAT IS A 10

Transmission Completed; Nothing follows

ARROWS

Radio Handlers

ETA

Estimated Time of Arrival

CUMBA

Illegal Radio Users

ETD

EYEBALL

To Meet / See You

Estimated Time of Departure

CODE 66

Patient Emergencies

GO AHEAD

Proceed with your Message

77

Conference

WILCO

Will Comply

T3

Telephone Call

SPELL OUT

Please spell out phonetically

R3

Radio Call

CODE 55

Turn on your Cell Phone

CODE 99

FOR RESIDENTS

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SERGEE

Surgical Resident on Duty

PREPPY WHITE

Patient not injured / Sick

MEDEE

Medical Resident on Duty

PREPPY GREEN

Patient stable / not in danger

OBEE

OB-GYNE Resident on Duty

PREPPY YELLOW

Patients need medical attention

PEDEE

Pediatric Resident on Duty

PREPPY RED

Patient in critical / life threatening condition

ANEE

Anesthesiology Resident on Duty

PREPPY BLACK

Patient dead

FIVE-O

Nursing Supervisor on Duty

PREPPY ORO

Patient for elective operation

EMDEE

Non-Arrow Physician e.g. Dr. Cruz— MD Cruz

PREPPY ORO STAY

Patient for emergency operation

PREPPY

Patient

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LIFELINE AMBULANCE CODE SHEET

TEN CODE

TRANSLATION

TEN CODE

TRANSLATION

10-1

Signal weak / receiving poorly

10-30

Against rules and regulations

10-2

Signal good

10-35

Confidential information

10-3

Stop Transmitting

10-36

Correct time is

10-4

Okay

10-37

Wrecker needed at

10-5

Relay Message

10-38

Ambulance needed at

10-6

Disregard last information

10-39

Your message delivered

10-7

Out of Service / Unavailable for call

10-42

Accident at

10-8

In service / Available for call

10-45

Traffic tie-up

10-9

Please Repeat

10-45

10-10

Transmission Completed

All units available (or in vicinity), Response

10-12

Monitoring, Will not respond

10-46

Gas up

10-13

Advise road traffic condition

10-56

Meal time

10-14

Any message for me

10-67

All units comply

10-15

Call in your bill by T3

10-70

Fire at

10-17

Urgent Business

10-71

Report progress of fire at

10-19

Nothing for you

10-75

Cannot see intended party

10-20

Location

10-76

Money (payment)

10-21

Call by telephone

10-77

Assemble at

10-23

Stand by

10-84

Telephone number is

10-25

Do you have contact with?

10-85

Address is

10-26

Locate and raise for an R3

10-89

What is the agenda?

10-27

Move to channel

10-90

Attention all arrows

10-28

Identify your station

10-200

Police assistance needed

PHONETIC ALPHABET A–ALPHA B–BRAVO C–CHARLIE D–DELTA E–ECHO F–FOXTROT G–GOLF H–HOTEL I–INDIA J–JULIET K–KILO L–LIMA M–MAMA N–NOVA O–OSCAR P–PAPA Q–QUEBEC R–ROMEO S–SIERRA T–TANGO U–UTAH V–VICTOR W–WHISKY X–XRAY Y–YANKEE Z–ZULU

TERMS

HOSPITALS

ALPHA

Ambulance

MEDCITY

The Medical City

ORO

Operating Room

MAKATIMED

Makati Medical

TETRA

Hospital / ER

CAPITOL

Capitol Med

CODE 33

You need not come anymore

MDH

Manila Doctor’s

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Radio Medical Reports Reports must be made to medical personnel as park of almost every call. These reports may be by radio, verbally (in person), in writing, or in all three ways. The radio report is specifically structured to present pertinent facts about the patient without telling more detail than necessary. Too much detail ties up the radio frequency and takes up the time of hospital personnel.

In an effort to protect patients privacy, some hospitals encourage EMTs to use the telephone at the patients house or a cell phone en route to the emergency department rather than the radio. Follow your local protocols. (Lifeline protocols is to use ambulance or crew cellphone only).

Experienced EMTs try to “paint a picture” of the patient in words. This requires knowledge of radio procedure and practice. If you have a critical patient, your radio report should make that clear. This can be done by describing the chief complaint, injuries, vital signs, treatments, and mechanism of injury. Even with critical patients you must keep a clear, steady tone to your voice. Resist the urge to talk fast or appear excited as it will prevent effective communication.

Twelve parts of a Radio Medical Report A medical radio report has 12 parts. The following example, broken into its individual parts, shows a report you might make to the hospital:

1. Unit identification and level of provider

Memorial Hospital, this is Community BLS Ambulance 6 en route to your location ...

2. Estimated time of arrival ... with a 15-minute ETA.

3. Patient’s age and sex

We are transporting a 68-year-old male patient...

4. Chief complaint

... who complains of pain in his abdomen.

5. Brief, pertinent history of the present illness

Onset of pain was 2 hours ago and is accompanied by slight nausea.

6. Major past illnesses

The patient has a history of high blood pressure and arthritis.

7. Mental status

He is alert and oriented, never lost consciousness.

8. Baseline vital signs

His vital sign* are pulse HK regular and full, respirations 20 and unlabored, skin normal, and blood pressure 134 over 88: SpO2 is 98 percent.

9. Pertinent findings of the physical exam

Our exam revealed tenderness in both upper abdominal quad rants. They did not appear rigid.

10. Emergency medical care given

For care, we have placed him in a position of comfort.

11. Response to emergency medical care

The level of pain has not changed during our care. Mental status has remained unchanged. Vital signs are basically unchanged.

12. Contact medical direction if required or if you have questions Does medical direction have any orders?

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After giving this information, you will continue with reassessment of the patient en route to the hospital. During that time, additional vital signs will be taken, there may be changes in the patient’s condition, or you may discover new information about the patient, particularly on long transports. In some systems you should radio this additional information to the hospital in a followup radio call while en route (follow local protocols).

When you contact medical direction, you may be given orders.

The on-line physician may order you to assist in administering the patient’s own medication, or order the administration of a medication you carry on the ambulance, or give other orders. In any case, the communication between you and medical direction must be clear and concise to avoid misinterpretations that can inadvertently harm the patient. For example, a patient may have a medication for chest pain called nitroglycerin. This medication, is one that you may assist the patient in taking (according to local protocols).

The medication should be given only if the patient’s blood pressure is above a certain level. If there is a misunderstanding between you and the physician and this medication is ordered improperly, harm may come to the patient.

To avoid misunderstanding and miscommunication, use the following guidelines when communicating with medical direction: • Give the information to medical direction clearly and accurately. Speak slowly and clearly. The physician’s orders will be based on what you report.

• After receiving an order for a medication or procedure, repeat the order word for word. You may also ask to do a procedure or give a medication and be denied by medical direction.

Repeat this also.

• If an order is unclear, ask the physician to repeat it. After you have a clear understanding of the order, repeat it back to the physician.

• If an order appears to be inappropriate, question the physician. There may have been a misunderstanding, and your questioning may prevent the inappropriate administration of a medication. If the physician verifies the order, he may explain to you why he has given you that particular order.

THE VERBAL REPORT At the hospital, you will give a written report on your patient to hospital personnel. However, since it will take some time to complete your written report, the first information you give to hospital personnel will be your verbal report.

As you transfer your patient to the care of the hospital staff, introduce the patient by name. Then summarize the same kind of information you gave over the radio, pointing out any information that is updated or different from your last radio report. Include the following in your verbal report: • Chief complaint • History that was not given previously • Additional treatment given en route • Additional vital signs taken en route

INTERPERSONAL COMMUNICATION Team Communication As an EMT. you are part of a team of health care professionals. For example, at the scene, you may need to communicate with first responders (trained Emergency Medical Responders or others who have reached the scene and provided care before your arrival) or with advanced providers (Advanced EMTs or Paramedics). On many medical calls, a home health care aid or family member may be at the scene who can provide you with valuable information about the patient and the present emergency. You will need to speak candidly and respectfully with these members of the health care team in order to gather important information about the patient and in order to complete any necessary and appropriate transfer of care.

Therapeutic Communication Although communication between two or more human beings is a skill that you have learned over the years, many people still do not communicate as well as they could. Communicating with patients and others who are in crisis is even more difficult. Although interpersonal communication could be presented as a course in itself, the following guidelines will help when dealing with patients, families, friends, and bystanders: • Use eye contact. Make frequent eye contact with your patient. It shows

that you are interested in your patient and that you are attentive.

Failure to make eye contact signals that you feel uneasy around the patient. (If your pattern is avoiding eye contact, consider that in some cultures eye contact is considered rude. You may want to match your behavior to the patient’s in this situation.)

• Be aware of your position and body language. Your positioning in respect to the patient is important. If you are higher than the patient, you may appear intimidating. If possible, position yourself at or below the patient’s eye level. This will be less threatening to the patient. Body language is also important. Standing with your arms crossed or not directly facing the patient (a closed stance) sends a signal to the patient that you are not interested. Use a more open stance (arms down, facing the patient), when it can be done safely, to communicate a warmer altitude.

A closed or more serious stance may sometimes be beneficial, however, when you need to calm or direct bystanders at the scene. Standing above a patient may convey authority and can be done to gain control when necessary. Watch the patient’s body language to see how your communication with him is going. If the patient uses a closed stance, your communication efforts may not be working.

• Use language the patient can understand. Speak slowly and clearly. Do

not use medical or other terms that the patient will not understand.

Explain procedures before they are performed, to prevent anxiety.

• Be honest. Honesty is important. You will frequently he asked questions that you will not have the answer to: “Is my leg broken?”

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“Am I having a heart attack?” At other times you will know the answer to the question, but it is not pleasant: “Will it hurt when you put that splint on?” If the answer is “Yes,” tell the truth. Explain that you will do it as gently as possible to reduce pain, but some pain may he experienced. It is much worse to lie to the patient and have him find out that you were not being truthful. This will erode the patient’s confidence in you as well as in other EMTs and medical personnel the patient may meet later on.

• Use the patient’s proper name. Especially with senior citizens and other adults, do not assume familiarity. As a general rule, call patients as they introduce themselves to you. If a person many years older than you introduces himself as Juan Dela Cruz, it might be best to call him Mr. Harris as a sign of respect. Immediately calling him “Juan” when he clearly stated his name was “William” would be disrespectful. If, after you call him “Mr. Harris,” he says “Please call me Juan,” you have shown respect and can then use the less formal name. If in doubt, ask the patient what he would like to be called.

• Listen. If you ask the patient a question, get an answer, then have to ask again, it will show the patient that you were not listening.

If yuu are not listening, the patient will feel that you are not interested in what he has to say. or that you just don’t care. If you ask a question, wait for the answer. Then write it down so you will not forget.

COMMUNICATION AND DOCUMENTATION If a person has a mental disability or is hard of hearing, speak slowly and clearly. Do not talk down to the patient. If the patient has a hearing disability, he may read lips. In any case, seeing your lips may help him understand what you are saying. Therefore, be sure that a deaf or hearing-impaired person can see your mouth when you talk.

Remember that a person who is blind or has a visual deficit can usually hear, so do not give in to the temptation to speak to him loudly or unnaturally. For the visually impaired person, you will want to take extra effort to explain anything thai is happening that he cannot see.

You may also find people who do not speak the same language as you. In this case, use an interpreter (for example, a family member or friend who speaks both languages) or a manual that provides translations. Family members arc not always familiar with medical terminology, so you should he cautious using them. It is usually possible to get a professional translator through the phone company. You may also find that your communications center or medical direction has someone available who speaks the patient’s language.

The elderly are a rapidly growing segment of the population who often need EMS care. These older patients may have medical problems simply because of their age.

They may also be more prone to falls and serious injury from trauma due to the condition of their bones and body systems.

Many elderly patients are well oriented and physically able. Others, however, may have problems with hearing, sight, or orientation that have come on with age. These patients may seem confused or may simply find it difficult to communicate. In spite of their sensory limitations, of course, these patients still have needs and feelings. They deserve patience, kindness, and understanding—along with proper emergency care.

PEDIATRIC NOTE Since children sometimes can be difficult to assess and communicate with, it is often best to involve the parent* of the child when communicating Two roles of communication are critically important to children: • Always come down to the child’s level. Never stand above a child, as you will literally tower over the child and appear very intimidating. Crouching down reduces the size difference and greatly improves communication. II the child is not crucially ill, you might even take the time to sit on the floor and get slightly below the child in the beginning.

• Children often sense lies even faster than adults. It is important to tell the truth to children Remember, you may be the Fust contact from the EMS system that the child has ever had. Work to make it positive

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Huwag na huwag ka magsisinungaling, lalo na sa mga batang pasyente. Mabilis nilang nalalaman kung sinungaling ang kausap nila.

PREHOSPITAL CARE REPORT The record that you produce during a call is called a prehospital care report or, informally, a PCR. Your region or service may use a different name for the same kind of document, such as trip sheet, run report, or another name.

Prehospital care reports vary from system to system and country to country. Although the information that is required to complete each is relatively similar, the method used to record the data may be somewhat different. Written reports are those that have portions with narrative areas, areas to record vital signs in written number form, and check boxes.

Many, perhaps most, prehospital care reports are now done by direct data entry. This can take several forms. An electronic clipboard is a computer in a clipboard format. The computer is able to recognize handwriting and convert it to computer text. The data are stored and eventually downloaded to a larger computer.

More commonly used tools are laptop or pen-based computers in the ambulance. They allow the EMT to enter information about a call directly into a database.

One of the most popular methods is the web-based approach. With this increasingly popular method, the EMT signs on to a secure website and enters the data through a keyboard. With all of these methods, the EMS uses a printer at a receiving hospital to print out a hard copy of the report for the Emergency Department staff.

Whenever possible, you should complete the PCR while you are still at the receiving facility with fresh memory of the call. Since it is not always possible to complete the PCR before a crew has to leave, many EMS agencies using electronic data collection employ a drop report or transfer report. This is an abbreviated report containing the minimum data set, described later.

Functions of the Prehospital Care Report The prehospital care report has many functions It is the record of patient care, serves as a legal document, provides information for administrative functions, aids education and research, and contributes to quality improvement. These functions are discussed in the following paragraphs.

Patient Care Record The prehospital care report conveys important information about the patient to members of the Emergency Medical System and beyond. Although you provide a verbal report to the hospital staff before you leave the patient, your written record allows Emergency Department personnel to see the status of the patient when you arrived on-scene, the care you gave, and how the patient’s status may have changed during your care.

An example of this would be the Emergency Department staff looking back at your original set of vital signs to compare the patient’s current condition with the patient’s condition when he was first found at the scene. A copy of the prehospital care report becomes part of the patient’s permanent hospital record.

Legal Document The prehospital care report also serves as a legal document, which may be called for at any legal proceeding resulting from the call. The person who wrote the report will ordinarily go to court with the form. If the patient was the victim or perpetrator of a crime, the report and the writer may be called into court to testify about the call during criminal proceedings. Civil law proceedings for negligence in injuries (e.g. if a patient falls in a shopping mall and sues) are another reason that your report may be examined.

Unfortunately, there may be a time when the report is being examined because you are the subject of a lawsuit. Fortunately, this is rare and usually preventable.

In a case like this, the report in which you documented the circumstances and the care you gave will be very important.

Administrative Purposes Depending on the service you belong to, you may have to obtain insurance and billing information from (he patient or patient’s family. This may be recorded on your prehospital care report, on a separate form, or on both.

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Education and Research

Quality Improvement

Your report may be examined later as part of a research project.

Analysis of statistics compiled from prehospital care reports can reveal patterns and trends in EMS management and care. For example, analysts may see instances in which response time can be improved or different ways of scheduling and deploying units to prepare for busy areas and times.

Statistics also may justify a request for additional resources. Prehospital care reports can help management keep track of each EMT’s experience and skills. Extra practice may be scheduled during continuing education sessions for skills that the reports reveal are underutilized, for instance.

When an unusual or uncommon type of call takes place, the prehospital care report may he used as a demonstration of how to document such a case after it is stripped of data that might identify the patient.

Elements of the Prehospital Care Report Data Elements Each individual box in the prehospital care report is called a data element. Although some elements may seem insignificant, each is actually an important part of the report and the description of the patient and response. These elements are necessary for research as well as for documenting the call In the United States, to aid in EMS evaluation, the National Highway Traffic Safely Administration (NHTSA) has developed a data set of over 400 elements.

There is a standardized definition of what each element means so that regions and states can consolidate and compare their data. There is also a minimum data set containing a much smaller number of elements that all prehospital care reports should have nationwide. The NHTSA data set has been widely adopted by other countries such as the Philippines.

The prehospital care report can be broken down into two sections: run data and patient information. The format for data varies, depending on whether it is a paper report or an electronic report as well as the specific information required by your service. Formats you may encounter may include check boxes, short answers and narrative sections for longer answers.

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Most organizations have a Quality Improvement (QI)—also known as a Quality Assurance (QA) or Continuous Quality Improvement (CQ1)—system in place by which calls are routinely reviewed for conformity to current medical and organizational standards.

Examination of prehospital care reports is one major way of conducting this review.

At times, QI evaluations reveal excellent care by an EMT team that deserves special recognition and a “pat on the back.”

Minimum Data Set PATIENT INFORMATION This information is gathered at the time of the EMT’s initial contact with a patient upon arrival at the scene, following all interventions, and upon arrival at the medical facility: • Chief complaint • Level of responsiveness (AVPU)—mental status • Systolic blood pressure for patients greater than 1 years old • Skin perfusion (capillary refill) for patients less than 6 years old • Skin color and temperature • Pulse rate • Respiratory rate and effort

ADMINISTRATIVE INFORMATION • Time of incident report • Time unit notified • Time of arrival of patient • Time unit left scene • Time of arrival at destination • Time of transfer of care

Run Data

Spaces for run data, which may be provided at the beginning or end of the report form, include the agency name. date, times, call number, unit personnel and levels of certification, and other basic information as mandated by your service. Times recorded must be accurate and synchronous (by clocks or watches that show the same time). Be sure to use the time as given by the dispatcher when noting times on your report. Unless your watch or the ambulance clock displays exactly the same time as the dispatch center, the times on your report will not match. There may be a difference of several minutes between the time displayed on your watch and the dispatch center’s official time.

This time difference may seem insignificant but is actually very important in such areas as determining how long a patient has been in cardiac arrest, trends in patient condition, or measurement of system efficiency in response times.

Patient Information This section contains information about the patient. Specifically, it typically includes: • Patient’s name, address, and phone number • Patient’s gender, age. and date of birth • Patient’s weight • Patient’s race and/or ethnicity • Billing and insurance information (in many jurisdictions)

Information Gathered during the Call Following the run data and basic patient information, prehospital care reports provide areas for information about the entire call. This information may include:

• Your general impression of the patient • A narrative summary of events throughout the call, including the chief complaint, history of the present illness, past medical history, physical exam, and care • Specific sections to detail prior aid, past medical history, physical exam results, vital signs. ECG results, procedures and treatments, medications administered, and other information about the call as required by your service • Transport information Ang report mo ay magsisilbing gabay sa mga doktor na magbibigay ng mas mahabang lunas sa pasyente.

The narrative section or sections of a prehospital care report are less structured than Gawin mong malaman at the fill-in or check-box sections. It provides spaces to write information about the patient madaling maintindihan ang that cannot fit into fill-in blanks or check-off boxes. In a paper report, the space provided iyong report. for narratives is still somewhat limited. In an electronic report, however, the space for the

Narrative Sections

narrative will typically expand as needed. Even though the electronic space is expandable, and you want to include all important information, you should still strive to write clearly and concisely as a courtesy to those who will need to read your report.

Experienced EMTs consider a good prehospital care report as one that “paints a picture” of their patient. The report, as mentioned previously, is read by many people and is a vital part of the patient’s record. When hospital personnel or your Quality Improvement team reads your report, it should tell the patient’s story fully and appropriately.

Remember, you were invoked throughout the call and are familiar with the patient, his chief complaint, and the care you gave. The people who read your report will have no prior knowledge of the call or the patient. It is imperative that you provide complete, accurate, and pertinent information about your patient and present the information in a logical order.

The following guidelines will help you prepare narrative portions of your prehospital care reports.

•

Include both objective and pertinent subjective information. Objective statements are those that are observable, measurable, or verifiable, such as, ”The patient has a swollen, deformed extremity.” This is backed up by your visual observation. An objective statement might can also be, “The patient’s blood pressure was 110/80.”

Based on a measurement you took. Or it might be, “Patient uses a prescribed inhaler.” A verifiable fact provided by the patient.

Subjective information is information from an individual point of view. It may be provided by the patient as a symptom (“I feel dizzy”). It also may be provided by the EMT, such as your general impression of the patient (“Patient appears to have difficulty breathing”).

Avoid subjective statements that are merely opinions, are beyond your level of training or scope of practice (‘”I do not believe that the leg is broken” or “Patient is probably having a heart attack”), or are irrelevant (“Patient’s daughter was rude”).

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UNIT 2 DAY 10

Prehospital care reports are designed to be factual documents Use objective statements whenever possible and only pertinent subjective statements. If you record something you did not observe yourself, put it in quotation marks (e.g.. a bystander stated that,” The patient passed out at the wheel before crashing”). Placing a statement in quotation marks and identifying the source lets readers of the report know where the information came from.

The chief complaint is another piece of information that is usually given in quotes. If a patient is conscious and oriented, he will usually tell you why he or someone else called you (“My chest hurts”-). If the patient is not conscious or oriented, the person who called EMS may provide the chief complaint (She said he “felt faint and then passed out”). Since the chief complaint is in someone else’s words, it should be placed in quotes.

UNIT 2 In documenting your assessment procedures, remember toFUNDAMENTALS document important OF DAY 10 observations about the scene, such as suicide notes, weapons, and any other facts that would be important for patient care but not available to (he emergency department personnel.

EMT PRACTICE



Write legibly and use correct spelling. A prehospital care report will have absolutely no value if it cannot be read, so take the time to make your handwriting readable. Unclear writing, misread by others, may These are examination findings that arecause negative (things thatthe are not Additionally, true), your QI team will errors that could harm patient. unable to patient read the report review, and it will have no value for but are important to note. For example, if a patient has chest pain, you willbeask that if heforhas difficulty research or training. Spelling is also important. If you cannot properly breathing. If the patient says he does not have difficulty in breathing, that spell statement is itan piece a word, look upimportant (many ambulances and emergency departments medical dictionaries) or use another word. of negative information. On your prehospital care report, you would note,have “The patient denies difficulty Use medical terminology correctly. Be sure that any medical terms you breathing.” Negative information often applies to trauma patients. For example, if the mechanism of injury use are used correctly. If you are not sure of the meaning of a term, look it up a medical dictionary use everyday language to describe the indicates that there may be an injury to the arm but the patient says he feels noin pain, you wouldor note.”The condition instead. Careless use of medical terms could make your report patient denies pain in right arm,” Documenting pertinent negatives lets other medical thatresult in harm to the unclear or cause aprofessionals misunderstandingknow that might patient.

UNITthese 2 you thought to examine areas and that the findings were negative. Not documenting them might leave the  If it's not written down, you didn't do It. This is a statement that you will reader wondering ifDAY this10 area was explored at all. most likely hear from your instructor and experienced EMTs in the field. important of EMS Codes you mayIt explains use onanthe radioconcept may not bedocumentation. familiar Make sure that you document all your interventions thoroughly. If you did not docuto hospital personnel, so do notuseWrite them in written documentation.

Abbreviations, when used properly, make ment them, performed when the call legibly and use correct spelling. A prehospital care report willit will appear as if they were never later have absolutely value if it cannot beabbreviations read, so take the is time toreviewed. make writing efficient and accurate. However, usingnonon-standard will cause confusion and possibly your handwriting readable. Unclear writing, misread by others, may lead to errors in patient care. cause errors that could harm the patient. Additionally, your QI team willreport's most important function is to present an accurate The prehospital care be unable to read the report for review, and it will have no value forpatient's condition throughout the call, the patient's history representation of the A prehospital care report will have absolutely no value if it cannot research or training. Spelling is also important. Ifand youvital cannot properly signs, treatments performed, and changes or lack of changes in the spell a word, look it up (many ambulances and emergency departments patient's condition followingby treatments. be read, so take the time to make your handwriting readable. Unclear writing, misread others, may cause have medical dictionaries) or use another word. errors that could harm the patient.

Additionally, your QI team be medical unableterms to read the report for review, and it  Use medical terminology correctly.

Be surewill that any you use are used Spelling correctly. If you notimportant. sure of the meaning of a term, look properly spell a word, look it will have no value for research or training. is are also If you cannot “ it up in a medical dictionary or use everyday language to describe the up (many ambulances and emergency departments dictionaries) or use another word. condition instead. Carelesshave use of medical medical terms could make your report unclear or cause a misunderstanding that might result in harm to the Be sure that any medical terms you use are used correctly. If you are patient. not sure of the meaning of a term, up indown, a medical or usethat everyday  Iflook it's notitwritten you didn't dictionary do It. This is a statement you will language to describe the most likely hear from your instructor and experienced EMTs in the field. condition instead. Careless use of medical terms could make your report unclear or cause a misunderstanding It explains an important concept of EMS documentation. Make sure that you document all your interventions thoroughly. If you did not docuthat might result in harm to the patient. ment them, it will appear as if they were never performed when the call This is a statement that you will most likely hear from your is later reviewed. “

• Include pertinent negatives.

FUNDAMENTALS OF EMT PRACTICE

• •

• •

Avoid radio codes and non-standard abbreviations.

Write legibly and use correct spelling.

Use medical terminology correctly.

If it’s not written down, you didn’t do It.

instructor and experienced EMTs in the field. It explains an important concept of EMS documentation. Make The prehospital care report's most important function is to present an accurate representation of the patient's condition throughout call,not the patient's history them, it will appear as if sure that you document all your interventions thoroughly.

If youthedid document and vital signs, treatments performed, and changes or lack of changes in the they were never performed when the call is later reviewed. patient's condition following treatments.

The prehospital care report’s most important function is to present an accurate representation of the patient’s condition throughout the call, the patient’s history and vital signs, treatments performed, and changes or lack of “ changes in the patient’s condition following treatments.

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² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

T PRACTICE

EM FUNDAMENTALS OF

UNIT 2 DAY 10

FUNDAMENTALS OF EMT PRACTICE

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² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

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UNIT 2 DAY 10

T PRACTICE

FUNDAMENTALS OF EM Day 10

COMMUNICATION AND DOCUMENTATION SCUE INC. TRIP TICKET

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² Limmer (Brady)

³ Pollack, (AAOS) ⁴ NHTSA

SPECIAL DOCUMENTATION ISSUES Legal Issues There are several legal issues pertaining to prehospital care reports and other documents you may be asked to complete. These include issues of confidentiality, patient refusals, falsification, and error correction.

Confidentiality The prehospital care report itself and the information it contains are strictly confidential. The information must not be discussed with or distributed to unauthorized persons. The Health Insurance Portability and Accountability Act (HIPAA) requires ambulance services that are covered by the law to take certain steps to safeguard patient confidentiality. This typically includes placing completed PCRs into a locked box. HIPAA. stale, and local regulations will indicate lo whom the information may be distributed. Obviously, the receiving hospital must receive patient care information so they can treat the patient properly. Most reports have a copy that will he left at the hospital.

Patient Refusals It is one of the foremost causes of liability for EMTs and their EMS systems. Document all actions you take to persuade the patient to go to the hospital.

Additionally, you will have to make notes on the patient’s competency, or his ability to make an informed, rational decision on his medical needs. If the patient is noi capable of making this determination for any reason—including age. intoxication (alcohol and/or other drugs), mental competency, or as a result of the patient’s medical condition—you must document any actions you take to protect the patient.

The patient must he informed of the potential results of not going to the hospital or of refusing your care.

form. It is rare that a patient will refuse to sign the form. If he does, be sure to document this, as well, and note the names of witnesses to the refusal. If possible, when a patient refuses to sign a refusal form, get the witnesses lo sign a statement confirming that the patient has refused care or transport.

The fact that a patient refuses transport to a hospital does not mean that you should not perform an assessment. If the patient greets you with a statement such as.” I don’t know why my daughter called, because I’m not going anywhere,” you may still be able lo persuade the patient to get “checked out.” Perform as much of a secondary assessment as possible, including vital signs. Document all of your findings and emergency care given on the prehospital care report. This information will be important to give to medical direction when you talk to them. Be sure to consult medical direction, according to your local protocols, whenever there is a patient refusal.

You will note that the narrative shown here, contains many points of information, including pertinent negatives The report states that the patient “denies” chest pain or difficulty in breathing.

Statements from the patient’s daughter are noted as to the source: “according to her daughter...” and “The daughter denies seeing any seizure activity.”

Most EMS agencies have a refusal-of-care form to use in the event that you have done your best to persuade the patient to accept care or transport and the patient still refuse*. This form may be part of cither the prehospital care report or a separate document.

You should make sure the patient reads and signs this

You should also include information about the patient refusal in the narrative section of the prehospital care report. Figure below shows a handwritten sample documentation of a patient refusal that might go into the narrative portion of the prehospital care report

Before you leave the patient who has refused care or transport, be sure to make alternative care suggestions, such as encouraging him to seek care from a doctor, and document them. Try to be sure that a responsible family member or friend remains with the patient. Make sure that person also understands that the patient should seek care. Never convey the impression that you arc annoyed about being called to the scene “for nothing.” Make certain the patient understands that if his condition worsens or if he changes his mind, he can call EMS and you or another EMT learn will gladly come back.

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SPECIAL DOCUMENTATION ISSUES

Falsification Prehospital care reports document the information obtained and Ihe care rendered during the call. False entries or misrepresentations on a report are usually intended lo cover up serious flaws in assessment or in care. However, falsification may actually make the problem look worse when it is uncovered.

Two types of errors may he committed during a call: omission and commission. Errors of omission are those in which an important part of the assessment or care was left out.

An example is oxygen. If a patient is experiencing chest pain, oxygen is an appropriate treatment. If it is overlooked for any reason, never write that oxygen was administered when it was not.

Occasionally, because of events during transport to a hospital, an EMT may only be able to get one set of vital signs Never be tempted to write down an extra set of vital signs when none were taken. Just don’t do it! Document only the vital signs that were taken. If there is a reason why you have only taken one set. document the reason (e.g..”The patient became combative and disoriented en route, preventing a second set of vital signs”).

Errors of commission are actions performed on the patient that arc wrong or improper. An example of this is incorrect administration of medication. There are certain medications that you will he able to administer or assist the patient in administering to himself. This is a great responsibility. If a medication was administered when it was not indicated, it is important to tell medical direction and document the incident on the prehospital care report. Failure to document exactly what happened may have a negative effect on the patient’s care. The hospital may think that the patient’s condition is due to some other cause. In other situations, the hospital may re-administer the medication, not realizing that it had already been given.

Document the situation surrounding any error of omission or commission and explain exactly what happened. Document what was done to correct the situation, including advising medical direction and verbally notifying hospital personnel.

Falsification or misrepresentation on a prehospital care report leads to poor patient care because the facts were not documented, and hospital personnel may be misled about the patient’s condition and the care he received. Falsification or misrepresentation may also lead to the suspension or revocation of your certification or license as an EMT. You will avoid falsifications if you follow this rule: Write everything important that did happen and nothing that didn’t.

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Correction of Errors Prehospital care reports are not always written in ideal circumstances. You may even find yourself being dispatched to another call before you finish writing up your last one In situations such as this, you may inadvertently write incorrect information on the report.

Any time there is incorrect information on the report, it must be corrected. If the report is still intact (all copies attached and not yd distributed), draw a single horizontal line through the error, initial it, then write the correct information beside it. Do not completely cross out the error or obliterate it.This may appear to be an attempt to cover up a mistake in patient care.

If the error is discovered at a later date, after the report has been submitted, draw a single line through the error, mark the area with your initials and the date, and add the correct information to the end of the report or on a separate note. This should be done in a different color ink when possible so the change will be obvious. Copies of the report may have already been distributed to other agencies, your Quality Improvement committee, insurance companies, or attorneys, and a corrected copy may need to be sent. Make sure that you place the date on the changes so the most recent copy is identifiable. If information has been omitted and you wish to add it, be sure also to dale this information and place your initials by the added information.

If you have a direct data entry system instead of paper forms, you will simply log in to the system and make the correction.

Electronic data systems log every change made to a report, including the identity of the person making the change, so the process is relatively simple.

Whether you need to submit a copy of the revised form to the receiving hospital will probably depend on the seriousness of your change. Follow your agency’s procedures for correction of errors.

SPECIAL SITUATIONS Multiple-Casualty Incidents An incident in which there are many patients or injuries—such as a multiplevehicle collision, a major fire, or a plane crash—causes many logistical problems for an EMS system. Documentation of information for each individual patient may be difficult, A patient in a multiple-casualty incident (MCI) will probably be moved from one treatment area to another at the scene and then receive transport to a hospital. Patients may be transported to several different hospitals. It is very important to keep the information with the patient as he moves through the system. This is often done through the use of a triage tag. This tag is affixed to the patient and used to record the patient’s chief complaint and injuries, vital signs, and treatments given. At a point later in the emergency, the tag will be used to complete a traditional prehospital care report.

When completing a prehospital care report for a patient involved in a multiplecasualty incident, it will not be possible to provide the detail that you would normally provide for a single-patient call. This is an understandable consequence of the MCI. Your region or agency may have requirements for what information must be completed on the report during an MCI.

Special Situation Reports Many states use a supplemental form for advanced life support (ALS) calls or additional documentation for calls that were complex or involved.

Your activities as an EMT may also take you to some unusual situations that wilt require documentation on a form other than a prehospital care report. Such forms are usually specific to a local agency rather than mandated state wide. Some examples of situations that might require this kind of special report include: • • • • •

Exposure to infectious disease Injury to yourself or another EMT Hazardous or unsafe scenes to which other crews should be alerted Referrals to social service agencies for elderly or other patients in need of home care Mandatory reports for child or elderly abuse

This list is not all-inclusive. If there is any situation that requires extra documentation, the special report form may be the place to note it. It is important to remain accurate and objective when filling out this type of report, especially in an unusual or emotional situation. Follow local guidelines for the documentation of confidential information in these reports and for distribution of copies to appropriate agencies or persons.

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A sick patient needs medications to get well.

And as an EMT, you will find yourself dispensing medicine to your patient. Thus, you need the basic knowledge on how these medicine work.

This is the reason why you you need to study pharmacology.

In this chapter, you will lay the groundwork for your knowledge of drug administration to patients. Here you will be introduced to drug pharmacokinetics including absorption, distribution, biotransformation, excretion, elimination, tolerance, and dependence.

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You will also learn about the basics of pharmacology and you will practice medication administration via oral, parenteral, and inhaled routes. Part of the things you will study are dosage calculation, drug side effects, major drug groups, and specific drugs used in the field.

This will just be the basic. Your education as an EMT is a continuing process and you have to update your knowledge of the latest drugs available or prescribed for specific conditions.

Only by knowing what works and what does not work will you be able to improve your work as an EMT.

DAY

11

General Pharmacology Medications EMTs Can Administer Assisting in IV Therapy Medications Patients Often Take

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 Explain the rationale for the administration of medications.  Discuss general steps for assisting patient with self-administration of medications.

FUNDAMENTALS OF EMT PRACTICE Day 11  Read the labels and inspect each type of medication.

GENERAL PHARMACOLOGY INTRODUCTION

INTRODUCTION LEARNING OBJECTIVES As an EMT, you will be trusted with the tsk of administering medications in emer-

As an EMT, you will be trusted with the task of administering medications in emergency situations.

• Identify which medications will be carried on the gency situations. This important responsibility requires you to use critical decision This important responsibility requires you to use unit. making and pay attention to the detail. critical decision making and pay attention to the Although in many cases these medica• State the medications carried on the unit by the detail. Although in many cases these medicageneric name. tions may be lifesaving. there is the potential to do significant harm to the patient tions may be lifesaving. there is the potential to • Identify the medications with which the EMT-Basic may assist the patient with administering. when they are administered incorrectly. do significant harm to the patient when they are administered incorrectly.

• Explain the rationale for the administration of The study of drugs—their sources, medications. characteristics, and effects—is called pharma• Discuss general steps for assisting patient with selfThe administration of medica-tions. study of drugs—their sources, characteristics, and effects—is called pharmacology. This chapter introduces the terminology, cology.

This chapter introduces the terminology, basic principles, and rules rebasic principles, and rules regarding pharmacology.

• Read the labels and inspect each type of medication.

We will discuss medications EMTs carry on the garding pharmacology. We will discuss ambulance and review prescribed medications medications EMTs carry on the ambuyou may assist the patient in taking with approval lance and review prescribed medications you may assist the patient in taking Maging maingat sa from medical direction. You will learn the forms of paggamit ng salitang “drugs” with approval from medical direction. You will learn the forms of medications medications your patients may be taking as well as kapag may mga ordinaryong tao the names for common types of medications and why na nakakarinig sa iyo. Sa isip be taking as well as the names for common types of medicayour patients may they are used. kasi ng mga karaniwang tao, ang tions and why they are used.

Although you will learn many facts and terms “drugs” ay mga ipinagbabawal regarding medications, remember that nothing na gamot. Gamot na lamang replaces good judgment and proper decision making. o medikasyon ang salitang As always, the most important tool you carry is your Although you will learn many facts and terms regarding medications, remember gamitin mo para maiwasan ang brain. negatibong impresyon.

that nothing replaces good judgment and proper decision making. As always, the most important tool you carry is your brain.

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NOTE

NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe. Used with permission from Pearson Education, the publisher of the book.

MEDICATIONS YOU CAN ADMINISTER You will be able to administer or assist with six medications in the field: aspirin, oral glucose, oxygen, prescribed bronchodilator inhalers, nitroglycerin, and epi-nephrine auto-injectors. The information that follows is a brief introduction to each of these drugs. Your local system may allow additions lo this medication list. It is beyond the scope of this chapter, however, to include all the potential possibilities. However, if your system uses medications that are not covered here, be sure to obtain the appropriate information and education for those medications before administering them to a patient or check with Lifeline medical control on duty.

Medications on the Ambulance As an EMT, you will carry aspirin, oral glucose and oxygen on the ambulance. Under specific circumstances that will be described later, you will be able to administer these medications to patients.

Aspirin Many of you have taken a simple aspirin to relieve a headache or treat a fever. In the world of EMS. however, aspirin has a much more important role. As an EMT. you will administer aspirin to patients with chest pain of a suspected cardiac origin. In the event a heart attack is occurring, aspirin reduces the blood’s ability to clot and works to prevent the clot formation that causes damage to the heart. It is an exceptionally important medication under these circumstances. Fortunately, it is also very simple to administer. As ambulances typically do not carry drinking water, most services will carry chewable children’s aspirin and the patient will simply be asked to chew and swallow the appropriate dose.

There are very few reasons not to administer aspirin to a patient having chest pain of a suspected cardiac origin.

However, some patients do have allergies and others have gastro-intestinal bleeding that can be made worse by the administration of aspirin. Always follow your local protocols for administration guidelines or check with Lifeline medical control.

Oxygen Oxygen is a gas commonly found in the atmosphere.

Pure oxygen is used as a drug to treat any patient whose medical or traumatic condition causes him to be hypoxic (low in oxygen) or in danger of becoming hypoxic.

Throughout this text, you have learned— and will continue to learn—many situations in which a patient should be given oxygen.

Oral Glucose Glucose is a kind of sugar. Oral glucose has form of glucose that can be taken by mouth as a treatment for a conscious patient (who is able to swallow) with an altered mental status and a history of diabetes. Poorly managed diabetes often leads to low blood sugar. The brain is very sensitive to low levels of sugar, and this is commonly a cause of altered mental status. Oral glucose usually comes as a tube of gel that you can apply to a tongue depressor and place between the patient’s check and gum or under the tongue.

This allows the patient to swallow the glucose so it can be easily absorbed into the digestive tract and bloodstream, which carries it to the brain. This action may begin to reverse the patient’s potentially life-threatening condition. If the patient is conscious and there is no available glocuse gel, candy, sugar or softdrinks can be used as substitute.

Activated Charcoal Activated charcoal is a powder prepared from charred wood, usually premixed with water to form a slurry for use in the field. It is used to treat poisoning or overdose when a substance is swallowed and is in the patient’s digestive tract. Activated charcoal will absorb some poisons (bind them to the surfaces of the charcoal) and help prevent them from being absorbed by the body.

Egg white can be used as a emergency substitute in absence of activated charcoal. Adults 12 whole egg white can be swallowed and in children 8 whole egg whites.

Note: This is a Filipino remedy and may not apply in other countries.

Ang paggamit ng activated charcoal para sa mga biktima ng pagkalason ay pinapayagan sa maraming lugar.

Bagama’t hindi ito kasama sa anim na mga gamot na kadalasang dala ng aming mga EMT, ang paggamit sa activated charcoal ay itinuturo pa rin namin dito. Pag-aralan ang local proptocl sa lugar ninyo para malaman kung anong mga gamot ang puwede ninyong gamitin bilang EMT.

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Day 11

PHARMACOLOGY

PRESCRIBED MEDICATIONS The three medications described next—prescribed inhaler, nitroglycerin, and epinephrine auto-injector—are drugs that you, as an EMT, may assist the patient in taking if they have been prescribed for the patient by a physician.

Nitroglycerin

Bronchodilator Inhalers Patients can carry various medications to help them through a period of difficulty breathing.

Most often patients with diseases like asthma, emphysema, or chronic bronchitis carry a “bronchodilator.” a medication designed to enlarge constricted bronchial tubes, making breathing easier. Many of these medications can be carried in an inhaler, which contains an aerosol form of a medication the patient can spray directly into his airway. Examples of these medications include albuterol (Ventolin. Proventil, Volmax) and levalbuterol (Xopenex).

Since many bronchodilators also have an effect on the heart, an increased heart rate and patient jitteriness are common side effects of treatment.

Be sure to determine that the inhaler is actually the patient’s and not that of a family member or bystander. You may need to have permission from medical direction to help a patient self-administer a prescribed inhaler. This permission from medical direction may come by phone or radio, or there may be a standing medical order that permits you to assist a patient with this kind of medication. Always comply with the protocols of your EMS system.

Many patients with problems such as recurrent chest pain or a history of heart attack carry nitroglycerin pills or spray. Nitroglycerin is a drug that helps to dilate the coronary vessels, which supply the heart muscle with blood. It is often called just “nitro.” A common trade name is Nitrostat.

This drug is taken by the patient when he begins to have chest pain he believes to be cardiac in origin. It is not uncommon for EMTs to treat patients who have already taken a nitroglycerin pill or who arc carrying a bottle of nitroglycerin tablets and have not thought to try one. (Many patients are instructed by their physician to take up to three nitroglycerin pills for their chest pain and. if the chest pain persists, to call EMS.) Be sure to determine that the nitroglycerin is actually the patient’s and not that of a family member or bystander.

Also determine whether the patient has recently taken anything to treat erectile dysfunction, such as sildenafil (Viagra), vardenafil (Levtra), tadalafil (Cialis). or similar medication. If so. he should not take nitroglycerin because of the possibility of a serious negative interaction with these drugs.

Since nitroglycerin causes a dilation of blood vessels, a drop in the patient’s blood pressure is always a potential side effect of administration. If this should occur, you may also need to lay the patient flat as you contact medical direction again for advice.

You may need to seek permission from medical direction by phone or radio, or there may be a standing medical order that permits you to assist a patient with nitroglycerin administration. Always comply with the protocols of your EMS system.

Epinephrine Auto-Injectors When a patient is highly allergic to something like shellfish, penicillin, or a bee sting, he may have a very severe reaction that may cause life-threatening changes in the airway and circulation. The reaction can be reversed by using epinephrine, a medication that will help to constrict the blood vessels and relax airway passages.

Because severe allergic reactions may reach a lifethreatening stage in a very short time, epinephrine must be administered quickly Many patients who are prone to severe allergic reactions carry an epinephrine auto-injector. This is a syringe with a spring-loaded needle that will release and inject epinephrine into the muscle when the auto-injector is pushed against the thigh. Epi-Pen™ is the trade name of a commonly carried epinephrine auto-injector. Twinject* is the trade name of an auto-injector that contains two doses of epinephrine. If you need to assist a patient with the use of an epinephrine autoinjector, be sure to determine that the auto-injector is actually the patient’s and not that of someone else.

Since epinephrine has a potent effect on the heart and vascular system, increased heart rate and blood pressure 274

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commonly occur after its administration to the patient.

You may need to seek permission from medical direction by phone or radio, or there may be a standing medical order that permits you to assist a patient with an epinephrine autoinjector. Always comply with the protocols of your EMS system.

An increasing number of states are expanding the scope of practice to allow the basic level EMT to carry and use an epinephrine auto-injector to treat life-threatening allergic reactions. The authority to administer epinephrine to the patient, rather than to assist a patient in the use of his own auto-injector, is normally granted by the Medical Director only after the EMT has received additional education and testing.

Many systems also carry ‘force protection medications” such as atropine in auto-injector form to treat responders in the event of a chemical weapons attack. Typically, you would administer these medications to yourself and your partner if you found yourself exposed to certain weapons of mass destruction like nerve gas. Local protocols will determine which of these medications (if any) are carried. Follow local guidelines for administration.

HOW MEDICATIONS FOR ASTHMA AND ANAPHYLAXIS WORK Medications are valuable tools to help patients in the most serious of medical emergencies. Some medications are carried by EMTs whereas others belong to the patients. You may be allowed to assist patients with taking their medications. This section discusses the pathophysiology of two common emergency presentations, asthma and anaphylaxis, and explains how medications available to the EMT work.

CONDITION Asthma

PATHOPHYSIOLOGY Small airways become reactive and constrict.

Air does not move in and out easily although exhaling is more difficult. This results in air trapping.

Upon auscultation of a full respiratory cycle, you will notice that the expiratory phase is prolonged.

Triggers” such as exercise, allergens, respiratory viruses, and even aspirin and non-steroidal antiinflammatory drugs (NSAlDs) cause this reaction.

Anaphylaxis

Anaphylaxis is a life-threatening response of the immune system. Anaphylaxis affects major systems such as the circulatory and respiratory systems and, if untreated, can cause death.

Anaphylaxis begins when the body overreacts to an antigen. Common causes of anaphylaxis are bee stings, peanut butter, and medication allergies.

The allergic reaction (begun when an antigen meets antibodies within the body) causes the body to release a variety of substances, including histamine, which cause vasodilatation and shock as well as bronchoconstric-tion.

These substances also alter vascular permeability, allowing lluid to enter and swell the airways, lips, tongue, and throat.

ACTION OF MEDICATIONS Albuterol is a medication very commonly used during asthma attacks. It is available in an in-haler and in a small volume nebulizer (SVN).

Albuterol must actually enter the smaller airways—it acts upon contact. Albuterol acts on the (beta2) receptors of the sympathetic nervous system, which results in dilation of the airways.

The fact that albuterol acts primarily on the specific receptors means there will be limited cardiac side effects (such as rapid heart rate).

The epinephrine auto-injector earned by patients and on many ambulances provides immediate and significant benefit to those suffering from anaphylaxis.

Epinephrine causes vasoconstriction (which reverses shock) by acting on the alpha receptors of the sympathetic nervous system. It reduces vascular permeability and the edema found in the lace and airways.

Epinephrine also causes bronchodilation to open constricted bronchioles through the beta receptors in the sympathetic nervous system.

GENERAL INFORMATION ABOUT MEDICATIONS Drug Names Every drug or medication is listed in a comprehensive government publication called the MIMS - Philippine Annual. Each drug is listed by its generic name (a general name that is not the brand name of any manufacturer). However, each drug actually has at least three names: the chemical name, the generic name, and one or more trade (brand) names given the drug by various manufacturers. For example, epinephrine is a generic drug name. Its chemical name is B-(3,4 dihydroxyphenyl)-amethylaminoethanol (Chemical names are technical fformulas used only by scientists or manufacturers.) As mentioned earlier, Epi-Pen* is the trade name nf an epinephrine auto-injector.

Mahalaga na malaman ang iba’t ibang pangalan ng gamot lalo na ang generic name nito at kung para saan ito para mas mabilis na makapagdesisyon ang isang EMT.

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What You Need to Know When Giving a Medication Every drug has an indication or indications, that is, specific signs, symptoms, or circumstances under which it is appropriate to administer the drug to a patient. For example, nitroglycerin is indicated when a patient has chest pain or squeezing-dull pressure. Each drug also has contraindications, or specific signs, symptoms, or circumstances under which it is not appropriate and may be harmful, to administer the drug to the patient. For example, nitroglycerin is contraindicated (should not be given) if the patient has low blood pressure, because nitroglycerin, in dilating the arteries, causes a slight drop in the systolic blood pressure. As noted earlier, nitroglycerin is also contraindicated if the patient has recently taken Viagra or a similar medication because of possible serious negative interac-tions.

A side effect is any action of a drug other than the desired action. Some side effects are predictable, like the drop in blood pressure from nitroglycerin. If you were not aware of the side effect of a drop in blood pressure and gave the drug to a patient who started out with low blood pressure, the results could be devastating. The patient’s blood pressure might “bottom out”—which is definitely not a desirable effect for a cardiac patient. Often medications have unintended effects; that is, effects that occur in addition to the specific reason the drug was administered. Occasionally, such an effect can be classified as an untoward effect or an effect that is not only unexpected, but also potentially harmful to the patient.

Medications come in many different forms.

A few examples are:

• Compressed powders or tablets, such as nitroglycerin pills, • Liquids for use outside the digestive tract, such as in an injection. This route is called the parenteral route and refers to bypassing the GI tract. An example of this type of medication would be epinephrine from un auto-injector.

• Liquids to be taken orally (like a cough syrup). This route utilizes the digestive tract to reach the bloodstream and is known as an enteral route.

• Liquid that is vaporized. such as a fixeddose nebulizer, • Gels, such as the paste in a tube of oral glucose • Suspensions, such as the thick slurry of activated charcoal in water.

• Fine powder for inhalation, such as that in a prescribed inhaler.

• Gases for inhalation, such as oxygen.

• Sublingual (under-the-tongue) sprays such as a nitroglycerin spray.

Medication Safety and Clinical Judgment Administering or assisting with medications is a serious responsibility, since if medications are given incorrectly they can cause serious harm to the patient. As an EMT, you need to use good judgment and carefully consider any medication you administer.

The back of an ambulance is a dynamic place. There are many distractions and many decisions you will have to make. However, when it comes time to make decisions about medications, you need to focus. Medication administration should only be undertaken after a thorough patient assessment. You must see all the factors that go in to safe medication administration. You must understand not only how this medication will impact the patient in general, but also how it will impact your current patient under the current, specific circumstances. — check with medical control.

Know the medication. If you are unsure about it, look it up. Never guess. Medical direction may be required for permission, but it may also be contacted for assistance.

Ask questions. An EMT must multitask routinely, but when it comes to medication administration you need to be singular of focus. This is the time to think only about the task at hand.

Once the medication is administered you cannot take it back. Focus, clear thinking, and good judgment—all will help assure a proper and safe treatment.

Again, when in doubt, Call medical control of Lifeline 16911.

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Maging maingat sa pagbibigay ng gamot. Ang isang pagkakamali dito ay puwedeng magdulot ng masamang epekto sa pasyente.

Magbigay lamang ng gamot matapos ang kumpletong pagsusuri sa lagay ng pasyente.

Medication Authorization As an EMT. you are authorized to administer medications by your Medical Director. This medical direction by the Medical Director may be service level, regional level, or even national level.

The authorization to administer medications can come in two different manners: • Offline Medical Direction – In this case, you will not actually speak to a physician to ask permission. Offline medical direction uses “standing orders”; that is. orders written down in the form of protocols. Providers learn these protocols and administer medications guided by the specific circumstances and conditions previously outlined in their rules and regulations.

• Online Medical Direction – In this case, you will need to speak directly to a physician (or his designee) to obtain verbal permission to administer a medication. Verbal confirmation is required. As an EMT, you should always be diligent to ensure you have heard and correctly understand the instructions. A useful technique to employ is the “echo technique.” In this technique, you will listen to the order and then repeat the order back. The physician then should give you a verbal confirmation that what you have heard is correct. Use of this process significantly reduces medication errors. If at any time you are confused or have a question, speak up. Asking for clarification while online is always appropriate.

The Five Rights Before administering a drug to any patient, confirm the order and write it down. Then check the “five rights” by asking yourself the following questions as you select the medication and confirm that it is not expired:

Routes of Administration

The route by which the drug is administered affects the rate that the medication enters the bloodstream and arrives at it’s target organ to achieve its desired effect. EMTs use the following routes of administration: • Oral, or swallowed. This route is very safe and has few complications associated with administration. However, since the medication must be digested to take effect, it also takes longer for the medication to become effective. Oral medications are typically given in pill or capsule form: however, liquids arc also a possible option.

• Sublingual, or dissolved under the tongue. This route also accesses the body through the mouth; however, in this case the medication is typi-cally placed under the tongue and allowed to dissolve. As it dissolves, the medication is absorbed by the vascular soft tissue of the mouth. This route is faster than swallowing pills, but absorption sometimes is difficult if circulation is poor (as in shock).

• Inhaled, or breathed into the lungs, usually as tiny aerosol particles (such as from an inhaler) or as a gas (such as oxygen). Inhaled medications are breathed in through the respiratory system, and the medication is absorbed into the bloodstream through the alveoli.

• Intravenous, or infected Into a vein. The intravenous route is beyond the scope of the EMT level. However, you should know that this is a fast and precise way to administer medications into the body by directly accessing the bloodstream through a vein.

• Intramuscular, or injected into a muscle. The intramuscular route injects medication directly into the muscle there, blood vessels can rapidly absorb the medication and transfer it to other parts of the body. This route typically uses a needle.

• Subcutaneous, or injected under the skin. Subcutaneous injections are very similar to intramuscular injections except that they deliver medications into the layers of the skin rather than into the muscle.

This results in a slightly slower absorption than with intramuscular injections.

• Intraosseous, or Injected into the bone marrow cavity. New technology {the “IO gun” or “IO drill”) allows rapid placement of a rigid needle into the bone marrow cavities of long bones such as the tibia.

• Endotracheal, or sprayed directly into a tube inserted into the trachea. This route is used in some ALS systems. Endotracheal medications are administered through a tube inserted into the trachea to he absorbed by the tissue of the lungs Recent evidence has questioned the effective-ness of this route, however, because lung tissue has very unpredictable absorption rates. Yet you may find this route still used as a last resort.

Bago magbigay ng anumang gamot sa pasyente, tanungin muna ang iyong sarili kung tama ba ang pasyenteng bibigyan mo ng gamot, kung tama ba ang gamot na ibibigay mo dito, kung tama ba ang dosage, at kung tama ba ang paraan ng pagbibigay mo ng gamot. Suriin din ang gamot para maseguro na hindi ito expired.

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Age and Weight-Related Considerations Pharmacodynamics is the study of the effects of medications on the body. It is important to consider pharmacodynamics anytime you administer a medication.

You should ask questions like: What effect will this medication have? How will it affect my patient? Remember that patient-specific factors can change how a medication will work. For example, a smaller, lighter patient, like a pediatric patient, will require less medication to achieve the desired effect. Often, geriatric patients will have difficulty eliminating medications and therefore feel the effects of medications longer. Consider age- and weightrelated dose changes, and always understand how the medication will affect your specific patient before administering it

Reassessment and Documentation

UNIT 2 DAY 11

After administering any medication you must reassess your patient. Essentially, you should begin your patient assessment again and look for any changes—improvements, deteriorations, or unintended effect—that the medication might have caused. Reassessment should occur immediately and be frequently repeated, especially with medications that take time to be effective.

It is also important to clearly document the medications you have administered. Good documentation must include the name of the medication (spelling counts), the dose of the medication, the route by which you administered it (be specific, as in “injected into the right upper thigh”), the lime of administration, and any effects you noted. Remember that the hospital will continue to give the patient medications and must know w hat has already been administered in order lo carry out a safe treatment plan.

ASS

MEDICATIONS PATIENTS OFTEN TAKE It would be impossible to learn and carry around in your head all the types of medications you might discover your patients are taking. However, the medications a patient is taking may be a clue to a pre-existing medical condition or, if improperly used, a cause of the patient’s current problem. For example, a patient who is taking antihypertensives and antidiabetics might also be taking or misusing other medications that can contribute to an altered mental status— perhaps Dilantin to control seizures, codeine for pain, or Inderal for a heart rhythm disorder.

Some medications that may be prescribed to a patient for daily use in managing a respiratory condition (one example would be beclomethasone, another would be Advair) should not be used to reverse an acute attack or to alleviate breathing difficulty.

It is a good idea to have a resource from which you can find out additional information about a patient’s medications en route to the hospital. Most EMTs carry with them, or have easily available access to a pocket guide that contains useful information such as commonly used drug abbreviations. These pocket guides usually list the most commonly prescribed medications along with the general category of that medication to help you understand what the medication may be used for. A high-tech version of this guide is available that can he carried on an smartphone or even a tablet. This high tech version is often more comprehensive than the paper version and more easily updated over the Internet.

Several apps are available, some of them at very

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little or no cost. However, remember that your main purpose in finding out what medications the patient is taking is not to make a field diagnosis but to report this information to medical direction and hospital personnel.

The lists of the seven most common categories of medications you will find in the field that are relevant to patient care, with a few examples of medications in each category. Lists of some common herbal agents patients sometimes take. A sizable number of people use these preparations, but they do not always think of them as medications that they should tell you about when you ask them what medications they, take. Some of these agents have powerful effects, both intended and unintended, and should be recorded on the prehospital care report. Many also have interactions with prescription or over-the-counter medications.

There are many other drugs and drug categories in addition to those listed in the table.

After any medication is given to a patient, it is important that you reassess the patient to see how the drug has affected him. Obtain another set of vital signs and compare them to the vital signs that you took before administering the medication. Ongoing patient assessment should include an evaluation of the changes in the patient’s condition and vital signs after administration of medication. Be sure to document the patient’s response to each drug intervention: for example. “The patient’s respiratory distress decreased after 5 minutes of high-concentration oxygen by nonrebreather mask.”

PREHOSPITAL EMERGENCY CARE

“

Set

IV th nou he a mos med

The One cath cath you used

FUNDAMENTALS OF EMT PRACTICE ASSISTING IN IV THERAPY

SISTING IN IV THERAPY

Setting Up An IV Fluid Administration Set Intravenous (IV) therapy is an advanced life support procedure.

In this procedure, an intravenous catheter is inserted into a vein so that blood, fluids, or medications can he administered directly into the patient’s circulation. A blood transfusion is almost always given at the hospital. whereas an infusion of other fluids and many medications can be done in the field.

There are two ways fluids and medications may be administered into the vein. One of these is through a heparin or saline lock. In this case, a catheter is placed into the vein. A small cap or lock is placed over the end of the catheter that protrudes from the skin. This lock contains a port through which you can administer medication. There is no IV bag attached to a saline lock. It is used in cases where fluid isn’t likely to be administered hut the administration of medications and/or the need for IV access inter on is likely.

The second way fluids can be administered is through the traditional IV bag, which hangs above the patient and constantly flows fluids and medications into the patient.

The bag of fluid that feeds the IV is usually a clear plastic bag that collapses as it empties The administration set is the clear plastic tubing that connects the fluid bag to the needle, or catheter. There are three important parts to this tubing:

• The drip chamber is near the fluid bag. There are two basic types: the micro drip (also sometimes called mini drip) and the macro drip. The micro drip is used when minimal flow of fluid is needed (with children, for example)- For example. 60 small drops from the needle in the drip chamber equal 1 cubic centimeter (cc) or 1 millilitre (mL). The macro drip is used when a higher flow of fluid is needed (for a multi-trauma patient in shock, for example). There is no needle in the drip chamber of the macro drip. It just provides 15 large drops equal to 1 cc or 1 ml. advanced life support procedure. In this procedure, an intrave-

tting Up an IV Fluid Administration Set

herapy is an us (IV) catheter is inserted into a vein so that blood, fluids, or medications can • The flow regulator is located below the drip chamber It is a device that can be pushed up or down to start, stop, or control the rate of flow. administered directly into the patient's circulation. A blood transfusion is alst always given at the hospital. whereas an infusion of other fluids and many • The drug or needle port is below the flow regulator The EMT can inject medication into this opening. dications can be done in the field.

An extension set includes an extra length of tubing, which can make it easier to carry or disrobe the patient without

ere are two accidentally pulling out the IV. Extension sets are sometimes not used with the macro drip set because lengthening ways fluids and medications may be administered into the vein. tubing reduces the flow rate. e of these is through a heparin or saline lock (Figure 18-9). In this case, a heter is placed into the vein. A small cap or lock is placed over the end of the heter that protrudes from the skin. This lock contains a port through LIFELINE whichPREHOSPITAL EMERGENCY CARE u can administer medication. There is no IV bag attached to a saline lock. It is d in cases where fluid isn't likely to be administered hut the administration of

279

UNIT 2 11 DAY DAY 11 DAY 11

FUNDAMENTALS EMT PRACTIC DAY 11 11 FUNDAMENTALS OFOF EMT PRACTICE DAY UNIT 2 FUNDAMENTALS OF EMT PRACTICE UNIT UNIT 2

UNIT DAY 11 2 UNIT 2 UNIT 2 DAY 11 DAY DAY 1111 FUNDAMENTALS OF OF EMT EMT PRACTICE PRACTICE UNIT 2 UNIT 2 11 DAY FUNDAMENTALS UNIT 2 DAY 11 FUNDAMENTALS OF EMT PRACTICE FUNDAMENTALS OF PRACTICE Day 11 DAY 11 PHARMACOLOGY FUNDAMENTALS OFEMT EMT PRACTICE DAY 11 DAY 11 1.

Takeout and inspect the fluid inspect the fluid

280

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2.

Select the proper administraadministration if an the administration set. if an do not let the ends touch the ground. the administration set. if an 3. Connect the extension set to the do not let the ends touch the do not let the ends touch the ground. tion set.

Uncoil the tubing, and do not the ends touch the ground. extension set islettoset beisused.

3. Connect the extension lo tionextension set.

Uncoil the tubing, and set is beset used. ground. extension set is to beto used.

3.extension Connect the extension to be used.set lo administration set. if an extension set is ground. ground.

3.not Connect the extension setthe lo do not the ends ground.

3.

Connect the extension set set. lois if an 4. Make sure the flow regulator doMake let thelet ends touch the the administration set. if touch an 4. sure the flow regulator is 3.

Connect the extension set lo 4.to be used.

Make sure the flow regulator is the administration 4. Make sure the flow regulator is 3. the Connect the extension set lo administration set. if an ground.

3.

Connect the extension set lo lo 3.

Connect the extension set the administration set. if an ground. closed.

To do this, roll the stopextension set isthis, to be used. the administration set. ifif an closed.

To do this, roll the stopextension setthis, is to roll be used. closed.

To do roll the stopclosed.

To do theanstopthe administration set. set an extension set is to be used.

3.

Connect the extension lo 4.

Make sure the flow regulator is closed. the administration set. if the administration set. if an extension set is tothe be used.

Connect the extension set lo extension set is to used. cock 4. away from bag 4. 3.

Make sure the flow is away from the fluid bag Make sure thefluid flow regulator cock away from the fluid bag extension setregulator is to be be used. cock away from the fluid bag is 4.cock Make sure the flow regulator is the administration extension set is used.

To do this, roll the stopcock away from extension setto isbe tocovering beroll used.

4.

Make sure the flow regulator is stopthe set. ifset. anif an 4.

Make sure the flow regulator is 5.

Remove the protective closed.

To do this, the 5.

Remove the protective covering To do this, roll the stop5. closed.

Remove the protective covering 4.administration Make sure the flow regulator is 5. Remove theflow protective covering closed.

To set do isthis, rollused. the stopextension to be 4.

Make sure the regulator is is the fluid bag closed.

To this, roll the stop4. Make sure the flow regulator extension set port is todo be used. closed.

To do this, roll the stopfrom the port ofport the bag cock away from the fluid bag from the of thebag fluid bag cock away from the fluid closed.

To do this, roll thebag stopfrom the port of the fluid bag cock away from the fluid 4.

Make sure the flow regulator is from the offluid the fluid bag closed.

To do this, roll the stopcock away from the fluid bag 5. Remove the protective covering 4.

Make sure the flow regulator is closed.

To do this, roll the stopcock away from the fluid bag Remove the protective covering and 5.the protective covering the protective covering cock away from the fluid bag 5. Remove the protective covering and5.and the protective covering Remove the protective covering closed.

To do this, roll the stopand the protective covering cock away from the fluid bag 5.

Remove the protective covering closed.

To do of this, rollfluid the stopfrom the port of the fluid bag and the away the fluid bagbag 5. Remove the protective from the from port of the fluid 5.

Remove protective covering from cock the spiked endcovering of from the spiked end ofbag (he from the port the bag from the spiked end offluid (he from thethe port ofthe the fluid bag cock away from fromthe the spiked end(heof (he 5.

Remove protective covering from the port of the fluid bag cock away from the bag 5. Remove the protective covering and protective covering protective covering from the spiked end from theInsert portthe of the fluid bag from the port of the fluid bag tuning. the spiked end of Insert thefluid spiked end of and the protective covering tuning.

Insert the spiked end of and the protective covering 5.tuning.

Remove the protective tuning.

Insert the spiked end of and the protective covering from the port ofspiked the fluid bag 5. Remove the protective covering from the end of bag (he and the port protective covering from the port of the fluid and the protective covering of the tuning. Insert the spiked end of the tubing into the fluid bag tubing into the fluid bag from the spiked of (he the of the fluid bag the the tubing into the fluid bag from the spiked end ofend (he the tubing into the fluid bag from the spiked end of (he and the protective covering from the port of the fluid bag from the spiked end of (he tuning.

Insert the spiked end of and the protective covering from the spiked end of (he the tubing into the fluid bag with a quick tuning.

Insert the spiked end of and the protective covering with a quick twist.

Do this carewith a quick twist.

Do this carewith a quick twist.

Do this caretuning.

Insert the spiked end ofend of with quick twist.

Doofthis caretuning.

Insert the spiked from theathe spiked endend (he and the protective tuning.

Insert thecovering spiked end of the tubing into the fluid from spiked end of bag (he tuning.

Insert the spiked of the tubing into the fluid bag from the spiked end of (he fully.

Maintain sterility, If these twist. Do this carefully. Maintain sterility, fully.

Maintain sterility, If these fully.

Maintain sterility, If these the tubing into the fluid bag the into the bag fully.

Maintain sterility, If of these tuning.

Insert the spiked end from with the end of fluid (he the tubing tubing into the fluid bag with athe quick twist.

Do this caretuning.

Insert the spiked end of aspiked quick twist.

Do this caretuning.

Insert the spiked end of the into the fluid bag touch the ground, they partstubing touch ground, they If these parts touch the ground, they parts touch the ground, they with aparts quick twist.

Do this carewith a quick twist.

Do this careparts touch the ground, they the tubing into the fluid bag with a quick twist.

Do this caretuning.

Insert the spiked end of fully.

Maintain sterility, If these fully.

Maintain sterility, If these the tubing into the fluid bag the tubing into the fluid bag with a quick twist.

Do this caremust not be used.

Introducing must not be used.

Introducing must not be used.

Introducing must not be used. Introducing germs or fully.

Maintain sterility, If these fully. sterility, If these must not be used.

Introducing fully.atouch Maintain sterility, If these the Maintain tubing into the fluid bag with aparts quick twist.

Do this care-caretouch the ground, they parts the ground, they with quick twist.

Do this with a quick twist.

Do this fully.

Maintain If into these germs or dirt directly into a germs or dirt directly ainto a parts touch the ground, they germs or dirt directly into a caredirt directly into a patient’s bloodstream parts touch the ground, they germs orsterility, dirt directly parts touch the ground, they with amust quick twist.

Do this carefully.

Maintain sterility, If these must not be used.

Introducing not be used.

Introducing fully.

Maintain sterility, If these fully.bloodstream Maintain sterility, If these parts touch thebloodstream ground, must not be used. patient's bloodstream can patient's canthey be patient's bloodstream can be be must not be used.

Introducing must not be used.

Introducing can be extremely serious, if not fatal. patient's can be fully.

Maintain sterility, If Introducing these parts touch thedirt ground, they germs or directly into germs or dirt directly into a parts touch the ground, they parts touch the ground, theya germs or dirt directly into a must not be used.

Introducing extremely serious, if not fatal. extremely serious, if not fatal. extremely serious, if not fatal. germs or dirt directly into a germs or dirt directly into a extremely serious, if not fatal.

6. Hold the fluid bag higher than the parts patient's touchnot thebloodstream ground, they patient's bloodstream can be must not be used.

Introducing can be must be used.

Introducing patient's bloodstream can be must notbag be higher used.

Introducing germs or dirt directly a than 6.

Hold the bag higher than 6.drip chamber. Squeeze the drip chamHold the fluid bag higher than 6. Hold fluid patient's bloodstream can be patient's bloodstream can be 6. the Hold the fluid baginto higher must not befluid used. extremely serious, if than not germs or dirt directly intofatal. a extremely serious, ifif not fatal. germs or dirtIntroducing directly into a extremely serious, not fatal. germs or dirt directly into a patient's bloodstream can be extremely serious, if not fatal. the drip chamber.

Squeeze the the drip chamber.

Squeeze the the drip chamber.

Squeeze the germs or dirt fluid directly into can a than extremely serious, if not fatal. drip the 6.the Hold thechamber. fluid bagSqueeze higher patient's bloodstream can bethan 6.

Hold the bag higher ber a time or two to start the flow. patient's bloodstream be 6.

Hold the fluid bag higher than patient's bloodstream can be 6.

Hold the fluid bag higher than extremely serious, if not fatal. drip chamber a time or two to drip chamber a time or two to drip chamber a time or two to patient's bloodstream can be the drip chamber.

Squeeze the 6. Fill the chamber to the marker line Hold the fluid bag higher than drip chamber a time or two to the drip chamber. extremely serious, ifSqueeze not fatal.the extremely serious, if not fatal. the drip chamber.

Squeeze the the drip chamber.

Squeeze the extremely serious, ifthe not fatal.

6. Hold the fluid bag higher than the flow. the chamber start the flow.

Fill the chamber the flow.

Fill the extremely serious, ifFill not fatal. drip chamber achamber time or two to start the flow.

Fill chamber the drip chamber.

Squeeze thetwo 6.start Hold the fluid bag higher than drip chamber a or to 6.start Hold the fluid bag higher than (approximately one-third full). drip chamber aa time time or two to drip chamber time or two to 6.

Hold the fluid bag higher the drip chamber.

Squeeze the t othe tdrip h em m a r k e r l i n e tHold o chamber t start h efluid a r k e l i n e t o t h e m a r k e r l i n ethelthan 6.drip bag higher than start the flow.

Fill the chamber the chamber.

Squeeze the the flow.

Fill the chamber t o t h e m a r k e r ine a time or two to the drip chamber.

Squeeze start the flow.

Fill the chamber 7. Open the flow regulator and allow start the one-third flow.one-third Fill the chamber the the drip chamber time or two (approximately full). (approximately thethe drip (approximately full). t odriptachamber. hone-third ea time m aor rSqueeze ktwo e to r full). tdrip ttthh e Squeeze m rrr kkkfull). eeeor rrrthe lll iii n ee chamber a aaatime two to (approximately one-third start Fill drip chamber tol i n e ttoflow. oochamber. m n h ee the mchamber ne the fluid to flush all the air from the drip chamber a time or two to start the flow.

Fill the chamber 7.

Open the flow regulator and 7. tOpen the flow regulator and drip chamber a time or two to (approximately one-third full). start the flow.

Fill the chamber (approximately one-third full).

7.

Open the flow regulator and 7. Open the Fill flowtheregulator o t h(approximately e m a r k e rone-third l i n efull). start the flow. chamberand (approximately one-third full). tubing. You may need to loosen the start the flow.

Fill the chamber allow the fluid to flush all the allow the fluid to flush all the t o t h e m a r k e r l i n e 7.

Open the flow regulator and start the flow.

Fill the chamber t o t h e m a r k e r l i n e 7.

Open the flow regulator and allow the fluid to flush all the 7.

Open the flow regulator and allow the fluid to flush all the (approximately one-third full). to the marker line 7. Open the flow regulator and cap at the lower end to get the fluid to tair oallow t htubing. eone-third m a r full). k flush emay rYouall l may i nthe e the fluid to full). allow the to the t ofrom t(approximately hthe eflow mregulator afluid r k eone-third r flush land i n all eall air tubing.

You may air from the tubing.

You may (approximately air (approximately from the You allow the fluid to flush the from theone-third tubing. allow the full).

7. Open the now. Maintain the sterility of the tubing 7.need Open the flow regulator and air from the tubing.

You may air from the tubing.

You may (approximately one-third full). (approximately one-third full). need to loosen the cap at the to loosen the cap at the 7.

Open the flow regulator and air from the tubing.

You may need to loosen the cap at the airfluid fromto flush all the need loosen the capand at the 7. Open thetoflow regulator allow the allow the fluid to flush need to loosen the cap at need toget the cap at the end and replace the cap when you 7. lower Open the flow regulator and 7.

Open the flow regulator end to the fluid toall lower end to get the fluid to allow the fluid toloosen flush allthe the need to loosen the cap at the the lower end to the fluid to need toget loosen lower end to get fluid to allow the fluid to flush all theand air from the tubing.

You may air from the tubing.

You lower end get fluid to lower end tosterility getflush the fluid to allow the fluid toto all the are finished. Most sets can be flushed allow the fluid to all the now.

Maintain the sterility of lower end toflush get the the fluidmay to now.

Maintain the sterility of air from the tubing.

You may lower end now.

Maintain the of now. the Maintain the sterility of air from tubing.

You may need to loosen the cap at the need to loosen cap the now.

Maintain the sterility of now.

Maintain the sterility of air tubing from the tubing.

You may now.

Maintain the sterility of air from the tubing.

You may the end and and replace theatthe the tubing end replace without removing the cap. Be sure now.

Maintain need to loosen the cap at the the tubing end and replace the the tubing end and replace the need to loosen the cap at the lower end to end getthe thecap fluid to lower to the fluidthe to the tubing end and replace the to tubing end and replace the need to loosen at the the tubing end and thewhen tubing replace the cap when you you areget finished. need to loosen the cap at the cap are finished. that all air bubbles have been flushed lower end get the fluid to caplower when you are finished. cap when you are finished. end to get the fluid to now.

Maintain theyou sterility of now.

Maintain the sterility of cap when are finished. cap when you are finished. cap when you lower end to get the fluid towithcap when arewithfinished.

Most sets can he flushed lower end to getsterility the to Most sets can he flushed now.

Maintain the sterility offluid from the tubing to avoid introducing a Most sets can he flushed withMost sets can he flushed withnow.

Maintain the of thenow. tubing end and replace the the tubing end and replace the Most sets can he flushed withMostMaintain sets can he flushed withsets he Maintain the sterility Most sets flushed without removing thecan cap.

Be sure now. the sterility of outMost removing the cap.

Beofsure the tubing end and replace the dangerous air embolism into the patient’s out removing the cap.

Be sure out removing the cap.

Be sure the tubing end and replace the cap when you are finished. cap you are finished. out removing the cap.

Be sure out removing the cap.

Be sure out removing the thewhen tubing end and replace the out removing cap.

Be sure that all air bubbles have been the tubing end and replace the that all air bubbles have been cap when you are finished. that allthat air bubbles have been vein. have cap when you are finished.

Most sets can he finished. flushed withthat all air bubbles have been Most sets can he flushed withthat all air thatall allair airbubbles bubbles have been been that all air have been capflushed when you are flushed from thebubbles tubing to from the tubing to cap when you are finished.

Most sets can he flushed withflushed from the tubing to flushed from the tubing to Most sets can he flushed with8. Turn off the flow. out removing the cap.

Be sure flushed from the tubing to flushed from the flushed from the tubing to out removing the cap.

Be sure flushed tubing to Most sets can he flushed withavoid introducing a dangerous avoid introducing a adangerous Most sets can he flushed without removing the cap.

Be sure avoid introducing a dangerous out removing the cap.

Be sure avoid introducing a dangerous that all air bubbles have been avoid introducing dangerous avoid introducing avoid introducing a dangerous avoid introducing a dangerous that all air bubbles have been out removing the cap.

Be sure air embolism into the patient's air air embolism into the patient's removing the cap.

Be sure that allout air bubbles have been air that embolism into the patient's flushed from the tubing to embolism into the patient's all air bubbles have air into the patient's air embolism into air embolism the patient's airembolism embolism into thebeen patient's that all air bubbles have been flushed from the tubing to vein. vein. that all air bubbles have been flushed from the tubing to avoid introducing a dangerous vein. vein. flushed from the tubing to vein. vein. vein. vein. flushed from the tubing to avoid introducing a dangerous 8. Turn off the flow.

8. Turn offembolism the flow. flushed from tubing to air the patient's 8. off the flow. avoid introducing aflow. dangerous 8.

Turn off the flow.

8.Turn Turn off the avoid introducing athe dangerous 8. Turn the flow.

8.off Turn off flow.

8.

Turn offthe the introducing ainto dangerous airavoid embolism into the patient's avoid introducing a dangerous vein. air embolism into the patient's air embolism into the patient's air embolism into the patient's LIFELINE vein.

PREHOSPITAL EMERGENCY CARE 8. Turn off the flow. air embolism into the patient's vein. vein. vein.

8. Turn off the flow. vein.

8.

Turn off thethe flow.

8.

Turn off flow.

8. Turn off the flow.

8. Turn off the flow.

Limmer Limmer (Brady) ² Limmer (Brady)(Brady) ²² Limmer (Brady) Pollack, Pollack, (AAOS) ³ Pollack, (AAOS)(AAOS) ³³ Pollack, (AAOS) ⁴ NHTSA NHTSA ⁴ NHTSA ⁴ NHTSA

² Lim ³ Pol

CE FUNDAMENTALS OF EMT PRACTICE E FUNDAMENTALS OF EMTUNIT 2 PRACTICE FUNDAMENTALS OF EMT PR FUNDAMENTALS OF EMT PRACTICE FUNDAMENTALS OF EMT PRACTICE DAY 11 FUNDAMENTALS OF EMT PRACTICE UNIT 2 FUNDAMENTALS OF EMT PR DAY 11 UNIT 2 DAY 11

UNIT 2 DAY 11

FUNDAMENTALS OF EMT PRACTIC FUNDAMENTALS OF EMT PRACTICE

“

“

“ “

Make certain that the setup slays clean until (he paramedic removes the needle and connects the IV tubing to the catheter inside the patient's vein. Occasionally, the paramedic will draw blood from the vein to obtain samples before inserting the IV, You may be asked to assist by placing the blood in sample tubes and labelling the lubes with the patient's name and any other information that your hospital requires. Remember that these tubes are potential carriers of pathogens.

Be sure to take Standard Precautions. Carry the blood lubes to a safe place Make certain that the setup stays clean until where they will not be in danger of breaking.

the paramedic removes the needle and connects the MakeDo certain the setup clean (hethe paramedic removes theminneed not bethat surprised if you slays arc asked to until hold up patient's arm for a few utesIV tubing to the catheter inside the patient’s vein. during a cardiac arrest.

During cardiacinside arrest,the medications beOccasiona more efand connects the IV tubing to the catheter patient'scan vein. fective if thewill armdraw is temporarily raisedthe aftervein a drug injected into thebefore IV. Occasionally, the paramedic or nurse will draw blood the paramedic blood from to is obtain samples insertin the IV, You may be asked to assist by placing the blood in sample tubes rem and from the vein to obtain samples before inserting the Make certain that the setup slays clean until (he paramedic belling the lubes with the patient's name and any other information that yo IV, You may be asked to assist by placing the blood in and connects IV tubing thetubes catheter insidecarriers the patient's ve hospital requires.the Remember that to these are potential of pathogen sample tubes and labelling the lubes with the patient’s the paramedic will draw blood from the vein to obtain samples Be surecertain to take that Standard Precautions. blood to a saferem pla Make the setup slays Carry cleanthe until (helubes paramedic name and any other information that your hospital where they not dangerto of breaking. the Youwillmay be by placing thethe blood in samp andIV, connects thebe IVinasked tubing toassist the catheter inside patient's ve

requires. Remember that these tubes are potential belling the lubes theblood patient's andtoany other inform the paramedic willwith draw fromname the vein obtain samples carriers of pathogens. Be sure to take Standard Do not be surprised if you arc asked to hold up the patient's arm for a few m hospital requires.

Remember that these tubes are potential carrie the IV, You may be asked to assist by placing the blood in samp Precautions. Carry the blood lubes to a safe place utes during a cardiac arrest. During cardiac arrest, medications can be more Be sure to take Standard Precautions.

Carry the blood lubes belling the lubes with the patient's name and any other inform fective ifwhere they will not be in danger of breaking. the arm is temporarily raised after a drug is injected into the IV. where they will not be in danger breaking. hospital requires.

Remember thatof these tubes are potential carrie Do not be surprised if you are asked to hold up the patient’s arm for a few minutes during a cardiac Be sure to take Standard Precautions. Carry the blood lubes Do notarrest. During cardiac arrest, medications can be be surprised if you arc asked to hold up the patient's arm where they will not be in danger of breaking. more effective if the arm is temporarily raised after a utes during a cardiac arrest. During cardiac arrest, medications fective ifbe thesurprised arm is temporarily after a drug is injected Do notdrug is injected into the IV. if you arc raised asked to hold up the patient'sinto arm utes during a cardiac arrest. During cardiac arrest, medications fective if the arm is temporarily raised after a drug is injected into ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

²² Limmer Limmer (Brady) (Brady) mmer (Brady) ³³ Pollack, Pollack, (AAOS) (AAOS) llack, (AAOS)

⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

281

Day 11

PHARMACOLOGY

CRITICAL CONCEPTS • Aspirin, oral glucose, and oxygen are medications carried on the ambulance that the EMT may administer to a patient under specific conditions.

• Prescribed inhalers, nitroglycerin, and epinephrine in auto-injectors are medications that, if prescribed for the patient, the EMT may assist the patient in taking.

• You may need to have permission from medical direction to administer or assist the patient with a medication. Follow local protocols.

• There is a wide variety of medications that a patient may be taking. You will try to find out what medications a patient is taking when you take the patient’s history. These drugs may be identified by a variety of generic and trade names.

Your main purpose in finding out what medications the patient is taking is to report this information to your Medical Director or hospital personnel.

Alamin kung anuanong mga gamot ang iniinom ng pasyente at isulat ito sa patient history.

Kailangan mong sabihin ito sa iyong Medical Director o sa tao ng ospital.

282

LIFELINE

PREHOSPITAL EMERGENCY CARE

MAINTAINING AN IV An IV must continue to flow at the proper rate once it has been inserted into the patient’s vein. However, a number of things may interrupt the flow. If you are charged with maintaining an IV. be sure to check for and correct the following problems: • The constricting band used to raise the vein for insertion of the needle may have been mistakenly left on the patient’s arm. perhaps covered by a sleeve.

• The flow regulator may be closed.

• The clamp may be closed on the tubing.

• The tubing may kink.

The tubing may get caught under the patient or the backboard.

The position of the IV or of the patient’s arm also may need to be adjusted. Some IVs only flow when the patient’s arm or IV site is in a certain position. Adjusting or even splinting, the arm may be helpful as long as the splint is not too tight. Since the IV flow usually depends on gravity, be sure that the hag is held well above the IV site and the patient’s heart.

Insufficient flow can cause blood to clot in the catheter. This can he prevented by adjusting the flow to an adequate “keep the vein open” or KVO rate. Although the KVO rate varies, it is usually about 30 drops per minute for a micro drip and It) drops per minute for a macro drip set. If the drip chamber is over-filled, clamp the tubing, invert the drip chamber and pump some fluid back into the bag.

An IV with a flow rate that is too fast is called a “runaway IV.” It can rapidly overload the patient with fluid and cause serious problems, especially in an infant or child. An infiltrated IV is one where the needle has either punctured the vein and exited the other side or has pulled out of the vein. In either case, the fluid is flowing into the surrounding tissues instead of into the vein.

An unnoticed infiltrated IV can be very dangerous. Certain highconcentration medications (such as 50 percent dextrose) can cause the death of the surrounding tissue. In addition lo complaining of pain, the patient will show swelling at the site (noticeable in all but some obese patients). The person in charge of maintaining the IV must stop the flow and discontinue the IV according to local protocol.

If you are not authorized to do this, report the problem immediately to the para-medic or medical direction.

If you learn how to help advanced life support personnel start an IV, set up an administration set. label blood tubes, and maintain an IV. valuable time can be saved at the scene and during transport.

MEDICATION PATIENTS OFTEN TAKE ANALGESIC: DRUGS PRESCRIBED FOR PAIN RELIEF Propoxyphene Nalbuphine (Nubain) Morphine (Astramorph PF, Duramorp, MS Contin, Roxanol) Acetaminophen (Anacin-3, Panadol, Tempra, Tylenol) Ibuprofen (Actiprofen, Advil, ExcedrinIS, Motrin, Novoprofen, Nuprin)

Aspirin (Ecotrin, Emprin) Codeine Oxycodone (OxyCotin) Naproxen (Naprosyn) Indomethacin (Indocin)

ANTIDYSRHYTHMICS: DRUGS PRESCRIBED FOR HEART RHYTHM DISORDERS Digoxin (Lanoxin) Propanolol (Inderal) Verapamil (Calan, Calan SR, Isoptin SR, Verelan) Procainamide (Procan SR, Promide, Pronestyl)

Disopyramide (Norpace) Carvedilol (Coreg) Metoprolol (Lopressor, Toprol XL)

ANTICONVULSANTS: DRUGS PRESCRIBED FOR PREVENTION AND CONTROL OF SEIZURES Carbamazepine (Epitol, Tegretol) Phenytoin (Dilantin) Primidone (Mysoline) Phenobarbital (Phenobarbital, Phenobarbital Sodium, Solfoton) Valporic acid (Depakene)

Lamotrigine (Lamictal) Topiramate (Topamax) Ethosuximide (Zarontin) Gabapentin (Neurontin) Levetiracetam (Keppra)

ANTIHYPERTENSIVES: DRUGS PRESCRIBED TO REDUCE HIGH BLOOD PRESSURE Captopril (Capoten) Clonidine (Catapres) Guanabenz (Wytensin) Hydralazine (Apresoline, Hydralazine HCL)

Hydrochlorothiazide (Esidrix, HydroDiuril, Oretic) Methyldopa (Aldomet) Nifedipine (Adalat, Adalat CC, Procardia) Prazosin (Minipress)

BRONCHODILATORS: DRUGS THAT RELAX THE SMOOTH MUSCLES OF THE BRONCHIAL TUBES. THESE MEDICATIONS PROVIDE RELIEF OF BRONCHIAL ASTHMA AND ALLERGIES AFFECTING THE RESPIRATORY SYSTEM Albuterol (Proventil, Ventolin, Volmax) Isoetharine (Bronkometer, Bronkosol) Metaproterenol (Alupent, Metaproterenol sulfate, Metaprel) Terbutaline (Brethaire, Brethine, Bricanyl) Ipratropium (Atrovent)

Saimeterol (Serevent) Albuterol/pratropium (Combivent, DuoNeb) Montelukast (Singulair) Zafirlukast (Accolate) Levalbuterol (Xopenex)

ANTIDIABETIC AGENTS: DRUGS PRESCRIBED TO DIABETIC PATIENTS TO CONTROL HYPERGLYCEMIA (HIGH BLOOD SUGAR) Glipside (Glucotrol) Glyburide (DiaBeta, Glynate PresTab, Micronase) Insulin (Humulin, Novolin, NPH, Humalog)

Hydrochlorothiazide (Esidrix, HydroDiuril, Oretic) Methyldopa (Aldomet) Nifedipine (Adalat, Adalat CC, Procardia) Prazosin (Minipress)

ANTIDEPRESSANT AGENTS: DRUGS PRESCRIBED TO HELP REGULATE THE EMOTIONAL ACTIVITY OF THE PATIENT TO MINIMIZE THE PEAKS AND VALLEYS IN THEIR PSYCHOLOGICAL AND EMOTIONAL STATE Amitriptyline (Elavil) Amoxapine Bupropion (Wellbutrin) Clomipramine (Anafranil) Venlafaxine (Effexor) Escitalopram (Lexapro) Fluoxetine (Prozac) Imipramine (Tofranil, Tripamine)

Nefazodone (Serzone) Nortriptyline (Aventyl, Pamelor) Paroxetine (Paxil) Protriptyline (Vivactil) Sertraline (Zoloft) Trimipramine (Surmontil) Citalopram (Celexa)

LIFELINE PREHOSPITAL EMERGENCY CARE

284

LIFELINE

PREHOSPITAL EMERGENCY CARE

DAY

NOT too long ago, the Philippine Medical Association threatened to sue owners of motor vehicles that failed smoke emission tests. Their reason: Motor vehicles are the top contributors to air pollution in Metro Manila which cause respiratory ailments among the residents of the metropolis.

According to a study conducted by the the Department of Environment and Natural Resources, air pollution in Metro Manila has already reached alarming levels. The air quality in the metro stands at 166 suspended particulates, which is almost double the 80-particulate threshold set by Republic Act 8749, or the Philippine Clean Air Act of 1999, for “good air.�

Because of the polluted air, it is not surprising that respiratory illnesses are on the rise. There are more Filipinos now who suffer from colds, cough, and asthma, which, if unchecked, usually develop into serious respiratory illnesses such as pneumonia and lung cancer.

As a future EMT, it is very important for you to know how to respond to respiratory emergencies. Breathing is the most important activity of us human beings. We can live for days without food or water, but we cannot live for minutes without air.

In this chapter, you will be taught how to respond to a person who is not breathing. You will know how to provide artificial ventilation, how to keep the airway open, and how to know if a patient is breathing adequately or not.

By the end of this chapter, it is our hope that you would be proficient in responding to respiratory cases and save more lives.

12

Respiration and Artificial Ventilation Airway Pathohysiology Chonic Obstructive Pulmonary Disease Pneumonia Air Delivery Devices

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RESPIRATION AND ARTIFICIAL VENTILATION LEARNING OBJECTIVES

INTRODUCTION

The cells of the human body must have oxygen to survive. The reason the ABCs—airway, breathing, and circulation—are so important is they are the means by which oxygen is brought into the body and transported to the cells. In this chapter we will discuss the airway, the “A” of the ABCs. and its role in delivering oxygen to the cells. You will learn that much of our primary assessment and treatment will focus on the airway The reason for this is simple: When the airway fails, air cannot reach the lungs.

When air cannot reach the lungs, oxygen cannot be delivered to the cells. In essence, without an airway, the patient will die. As you proceed through this chapter, keep in mind how important this statement really is.

• Identify and describe the airway anatomy in the infant, child and the adult and identify their differences.

• Describe the proper use of airway adjuncts.

• List complications associated with advanced airway management.

• Review the use of oxygen therapy in airway management.

In Chapter “Anatomy and Physiology,” you reviewed the anatomy and physiology of the respiratory system. In preparation for this chapter, you should review the following structures of the respiratory system and be able to label them on a blank diagram of the respiratory system: • • • • • • • •

Cricoid cartilage Carina Bronchi (right and left mainstem bronchus) Oropharynx Laryngopharynx Epiglottis Trachea Napakahalaga ng paghinga Larynx sa katawan natin. Ang ating katawan ay hindi mabubuhay kung walang oxygen. Kaya This chapter will also discuss a variety of topics naman sa chapter you have previously covered in the CPR course you na ito ay pag-aaralan took as a prerequisite to your EMT course. This natin kung papaano information included providing rescue breathing, matutulungan ang isang performing cardiopulmonary resuscitation (CPR), pasyente na hirap huminga. and treating airway obstructions in infants, children, and adults.

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Nose Mouth Tongue Nasopharynx Bronchioles Lungs Alveoli (alveolar sacs) Diaphragm

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• • • • • • • •

NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe. Used with permission from Pearson Education, the publisher of the book.

DAY 12

PRINCIPLES OF EMT CLINICAL PRACTICE AIRWAY PHYSIOLOGY

AIRWAY PHYSIOLOGY

“

UPPER AIRWAY

The movement of air into and out of the lungs requires an intact and open air-way, or patent airway. Thai means that air flow is unobstructed and capable of moving freely along its path.

In the upper airway. air enters the body through the mouth and nose.

The nose is specifically designed to accept air and, through a series of turns and curves,. Air is warmed and humidified as it proceeds through the nasal passages. The mouth is primarily designed to be the entrance to the digestive system, but it also is an entryway for air (especially in an emergency). Distal to the mouth and nasal passages, air enters the throat or pharynx.. The pharynx is divided into three regions: the oropharynx—where the oral cavity joins the pharynx; the nasopharynx—where the nasal passages empty into the pharynx, and finally the laryngopharynx—the thyroid cartilage protects the front and smaller air passages called The movement of air into and out of the lungs requires an intact and open airstructures surrounding the entrance of the larynx and forms the Adam’s bronchioles. All the air passages are way, or patent airway. Thai means that air flow is unobstructed and capable of to the trachea. apple, The cricoid ring, a complete supported by cartilage and are lined The laryngopharynx. also known circle of cartilage, forms the lower with smooth muscle. This smooth moving freely along its path. as the hypo pharynx, is designed to aspect of the larynx and provides muscle allows the bronchioles to provide structure to and protect, the structure to the proximal trachea. change their internal diameter in In the upper airway. air enters the body through the mouth and nose. The nose opening to the trachea. It also is the The lower airway begins below response to specific stimulation. is specifically designed to accept air and, through a series of turns and curves,. point of division between the upper the larynx and is comprised of the The bronchioles end at the alveoli.

Air is warmed and humidified as it proceeds through the nasal passages. The airway and the lower airway. The entry trachea, bron-chial passages, and the Alveoli are tiny sacs that occur in mouth isalveoli. From the glottic opening, primarily designed to be the entrance to the digestive system, but it point into the larynx, called the glottic grapelike bunches at the end of the also is anair enters the trachea. The trachea entryway for air (especially in an emergency).

Distal to the mouth and opening, is protected by a large leaf airway. These alveoli are surrounded like structure called the epiglottis. nasal passages, is a tube protected by 16 rings by pulmonary capillaries and it air enters the throat or pharynx..

The pharynx is divided into This protective flap that sits above the of cartilage. These rings provide is through their thin membranes three regions: the oropharynx—where the oral cavity joins the pharynx; the naglottic opening is designed to seal off structure and prevent the trachea that oxygen and carbon dioxide sopharynx—where the nasal passages empty into the pharynx, and finally the the trachea during swallowing or in from collapsing. The lop ring is the laryngopharynx—the structures surrounding are diffused. Gas exchange will be the entrance to the trachea. response to the gag reflex. The glottic cricoid ring, which extends fully 360 discussed in greater detail in the opening is also protected by the vocal degrees around. In the other rings following chapter. It is impor-tant The laryngopharynx. also known as the hypo pharynx, is designed to provide cords. These curtain like fibers that the cartilage extends only about to remember that the bronchioles structurethree-fourths of the way around and to. and protect, the opening to thedivide and travel in every direction. trachea. It also is the point of diviline either side of the tracheal opening not only can close shut for protection, is connected posteriorly by smooth As a result, tiny bronchioles and the sion between the upper airway and the lower airway. The entry point into the but also vibrate with the passage of air muscle. The trachea branches at the millions of alveoli they connect to larynx, called the glottic opening, is protected by a large leaf like structure called to create the voice. carina and forms two mainstem cover most anatomic regions of the the epiglottis.

This protective flap that sits above the glottic opening is designed The larynx itself is framed and bronchi. These large branches then chest from the collarbones to the to seal off the trachea during swallowing or in response to the gag reflex. The protected by cartilage. The shield like further subdivide to form smaller diaphragm.

glottic opening is also protected by the vocal cords. These curtain like fibers that line either side of the tracheal opening not only can close shut for protection, but also vibrate with the passage of air to create the voice.

The larynx itself is framed and protected by cartilage.

The shield like thyroid 287 LIFELINE PREHOSPITAL EMERGENCY CARE cartilage protects the front of the larynx and forms the Adam's apple, The cricoid ring, a complete circle of cartilage, forms the lower aspect of the larynx and provides structure to the proximal trachea.

Day 12

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AIRWAY PATHOPHYSIOLOGY In order for air to make the journey from the nose and mouth to the lungs, the pathway must be relatively unobstructed. A variety of obstructions can interfere with air flow. Foreign bodies like food and small toys arc common obstructions, as are fluids including blood and vomits. The airway can also be obstructed by the patient himself. A patent airway requires control of the muscles that form the airway. This is referred to as intact muscle tone. Conditions like altered mental status and neurologic disorders can result in a loss of this muscle lone and lead to collapse of the airway. A common obstruction in a person with a decreased mental status in the tongue —or, more precisely, the epiglottis connected to the tongue.

This obstruction occurs when a lack of tone causes the tongue to relax and fall back. When it does, the epiglottis falls back and cowers the entrance to the trachea. Often people consider this as the tongue obstructing the

airway but. in reality, the epiglottis actually causes the obstruction.

Airway obstruction can occur acutely, as in choking on a foreign body, or it can occur over time. Burns, blunt force trauma, and certain infections can cause swelling of the tissues or and around the glottic opening. This can also impede the movement of air. As such, it is always important to evaluate the patency of an airway not just in the immediate sense but also in an ongoing sense, “”Yes, the airway is open now, but will it stay open?”

In the lower airway, smooth muscle can constrict and decrease the internal diameter of the airway. Changing the internal diameter even slightly causes a sig-nificant increase in the resistance to air flow and can seriously impact the pa-tient’s ability to move air This is commonly referred to as broncho constriction or bronchospasm and is common in diseases like asthma.

PATIENT ASSESSMENT The Airway

These are really two questions you must consider when assessing a patient’s airway: “Is the airway open?” and “Will the airway stay open?”

Is the Airway Open?

You can determine the presence of an airway in most patients by simply saying hello. The patient’s ability to speak is an immediate indicator that he is capable of moving air. At the same time, a person who is unable to speak, or one that speaks in an unusually raspy or hoarse voice may be indicating to you a difficulty moving air. Stridor is a high-pitched sound generated from partially obstructed air flow in the upper airway.

This sound can be present on inhalation or exhalation (or both) and is an ominous sign of poor air movement. The sounds of breathing from the mouth and nose should be typically free of Para matiyak na humihinga gurgling, gasping, crowing, wheezing, snoring, and stridor. ang pasyente, gamitin ang “LookYou may also see patients use position to keep an airway Listen-Feel.” Tingnan, pakinggan at open. When swelling obstructs air flow through the upper pakiramdaman kung may pumapasok airway (typically duo to infection), patients may present in at lumalabas na hangin mula sa ilong o the ‘sniffing position.* You will notice a bolt uptight position bibig nito. Kung wala talagang hangin, with their head pitched forward as if they were attempting to kailangan mong bigyan ito ng rescue smell something. In a person with a partially obstructed airbreaths at simulan ang CPR. way, this position can be critical to keeping air moving.

Often it is not immediately apparent if an airway is present In your CPR class you learned about the “Look-ListenFeel” method. If a person is unconscious, you may need to employ this method to ensure an airway is present. In this case, look at the chest to see if it is rising and falling. The airway should also be visually inspected for foreign bodies including objects and fluid. You should listen at the mouth for sounds of breathing while placing your hand on the chest to feel for movement. You may also need to place your hand near the patient’s mouth to feel for air flow. In those cases you may detect subtle air movement that might not be apparent with just visual observation.

Remember that you assess the airway as part of the primary assessment and when you find a problem in the primary assessment, you must stop and fix that problem. In this case, if there is no airway present, stop and provide one.

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Will the Airway Stay Open?

The first part of this chapter discussed ensuring an open airway That is certainly important, but of equal importance now will be ensuring that the airway stays open. Airway assessment is not just a moment in time, but rather a constant consideration, especially in a critical patient. In some cases you may need to immediately consider how to keep an airway open after initially establishing it. In a person with no ability to keep an airway open, you may manually open it with a head-tilt and chin-lift. However, the moment you take your hands away, that airway will be lost. At this point you must consider additional steps. Similarly, if you identify a partially obstructed airway, you must ask yourself.

“How long will it be until this airway is completely obstructed?” and “What are the necessary steps to take to prevent or resolve this problem?” Consider the following examples: • You assess the airway of an unconscious victim of a fall off a ladder. He has no air so you apply the jaw thrust The airway opens and he begins to breathe.

However, when you take your hands away, the airway closes and he stops breathing. In this case the airway is open, but it will not stay open

• You assess a child after multiple bee stings. He speaks to you with a hoarse voice but is breathing. You note stridor on inspiration. He has an airway, but his voice changes indicate that his airway is swelling and partially obstructing air movement. How long will he be able to move air? What steps must you take immediately to keep air moving.

Remember also that the ability to maintain an airway can change over time. As mental status decreases, so might the ability to protect an airway. Always reassess this capability and remember that just because your patient has an open airway now, there is no guarantee he will continue to have an open airway later.

The Airway in the Primary Assessment — ABC 1. Is the airway open?

2. Are they able to speak?

3. Look • Visually inspect the airway to ensure it is free from foreign bodies and obvious trauma.

• Look for visual signs of breathing such as chest rise.

4. Listen • Listen for the sound of breathing.

• Listen for sounds of obstructed air movement such as stridor, snoring, gurgling, and gasping.

5. Feel • Feel for air movement at the mouth.

• Feel the chest for rise and fall.

6. Will the airway stay open?

• Are there immediate correctable threats?

• If no airway, then open it.

• Consider how you might keep open an unstable airway.

• Consider ALS for more definitive airway care.

7. Are there potential threats that may develop later?

• Reassess, reassess, reassess.

• Assess for signs of impending collapse such as stridor or voice changes.

• Consider conditions that may later threaten the airway (such as anaphylaxis).

Signs of an Inadequate Airway Signs that would indicate no airway or a potentially inadequate an way include the following • There are no signs of breathing or air movement.

• There is evidence of foreign bodies m the airway including blood, vomit, or objects like broken teeth.

• No air can be felt or heard at the nose or mouth, or the amount of an exchanged is below normal.

• The patient is unable to speak, ot has difficulty speaking.

• The patient has an unusual hoarse or raspy quality to his voice.

• Chest movement are absent, minimal, or uneven.

• Movement associated with breathing is limited to the abdomen (abdominal breathing).

• Breath sounds are diminished or absent.

• Noises such as wheezing, crowing, stridor, snoring, gurgling, or gasping are heard during breathing.

• In children, there may be retractions (a pulling in of the muscles} above the clavicles and between and below the ribs).

• Nasal flaring (widening of the nostrils of the nose with respirations) may be present, especially in infants and children.

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THE SOUNDS OF A PARTIALLY OBSTRUCTED AIRWAY

UN DAY

A partially obstructed airway can often be identified by the sounds or limited air movement. Understanding these sounds can help you belter understand the Pathophysiology of the obstruction.

Stridor Stridor is typically caused by severely restricted air movement in the upper airway. As air is forced by pressure through a partial obstruction, a high pitched, sometimes almost whistling sound can be heard, Typically stridor indicates a severely narrowed passage of air and suggests near obstruction. In stridor, the ob-struction can be a foreign body, such as a toy, or it can be caused by swelling of the upper airway tissues, as in an infection.

Hoarseness Voice changes, like stridor, often reflect a narrowing of the upper airway passages. Voice changes are often useful in assessing an ongoing airway issue. For example, in a person whose airway is swelling after a burn, you may note a normal voice to begin with, but a raspy voice as the swelling builds up around the vocal cords. The development of hoarseness is often an ominous sign.

Snoring Snoring is the sound of the soft tissue of the upper airway creating impedance (or partial obstruction) to the flow of air. Many persons normally snore while asleep, but snoring in the case of injury or illness can often indicate a decrease in mental status such that airway muscle tone is diminished. It is also an indication that the airway needs assistance to stay open.

Gurgling Gurgling it the sound of fluid obstructing the airway. As air is forced through the liquid, the gurgling sound is made. Common liquid obstructions include vomit, blood, and other airway secretions.

Gurgling is a sign that immediate suctioning is necessary.

PATIENT CARE The Airway

“

When the patient’s signs indicate an inadequate airway, a life-threatening condition exists and prompt action must be taken to open and maintain the airway. The following text explains the procedures for opening the airway.

Opening the Airway Assessing the airway will be one of the highest priorities of your assessment. When an airway problem is detected, it must be dealt with immediately.

For most patients, the airway can be assessed by simply assessing their speech. In a person with a diminished mental status, other steps may be necessary. In the latter case, the procedures for airway evaluation, opening the airway, and artificial ventilation are best carried out with the patient lying supine (flat on his back). Image illustrates the technique for positioning a patient found lying on the floor or ground Patients who are found in position other

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than supine or on the ground should be moved to a supine position on the floon strclchcr for evaluation and treatment.

Any movement of a trauma (injured) patient before immobilization of the head spine can produce serious injury to the spinal cord. If injury is suspected, protect the be and neck as you position the patient. Airway and breathing, however, have priority over pitection of the spine and must he ensured as quickly as possible. If the trauma patient be moved in order to open the airway or to provide ventilations, you will probably not time to provide immobilization with a cervical collar or head immobilization device

NIT 3 Y 12

To1.perform perform the head-tilt, chin-lift maneuver, follow these steps: Once thehead-tilt, patient is supine, place hand onbony the forehead and center place of the the fingertips ofchin-lift the other handone under the area at the To maneuver, follow these steps: 1.the Once the patient patient supine, place one hand hand onthe the forehead andplace place fingertips of theisisjaw. other hand under the bony area at the and center of the patient's lower 1.

Once the supine, place one on forehead the fingertips ofapplying the other other handpressure under the the bony areaatatthe thecenter centerofof patient's lower jaw. the fingertips the hand under area 2. the Tilt the head byof gentle tobony the patient's forehead. the patient's lower jaw.

2.3. Tilt theyour headfingertips bylower applying gentle pressure patient's the patient's jaw.

Use to lift the chin andtotothe support theforehead. lower jaw. Move 2.Use Tiltyour the head head by applying applying gentle pressure tothe theteeth patient's forehead.

3. 2. fingertips toalift the chin and tolower support the arc lower jaw. touching Move Tilt the by gentle pressure to patient's forehead. the jaw forward to point where the almost 3.the Use your fingertips to lift the chin and to support the lower jaw.

Move jaw forward to a point where the lower teeth arc almost touching 3.

Use your fingertips to lift the chin and to support the lower jaw.

Move the upper teeth. Do not compress the soft tissues under the lower jaw. the jaw forward tonot point where the lower teeth arcalmost almost touching the jaw forward to aa point where the lower teeth arc touching the upper teeth.

Do compress the soft tissues under the lower jaw. which can obstruct the airway. the upper upper teeth. Do Do not compress the thesoft softtissues tissuesunder underthe the lowerjaw. jaw. the teeth. compress canallow obstruct thenot airway.

4. which Do not the patient's mouth to he closed. To provide lower an adequate which can obstruct obstruct theairway. airway. which can the 4. Do not allow the patient's mouth to need he closed.

To the provide an adequate opening at the mouth, you may 10 use thumb of the hand 4.opening Do not notat allow the patient's mouth tohe he closed.

Toprovide provideof anthe adequate 4.

Do allow the patient's mouth to closed.

To an adequate the mouth, you may need 10 use the thumb hand supporting (he chin lo pull back the patient's lower lip.

Do not insert opening at at the mouth, you maythe need 10 use use the the thumb thumb theinsert hand opening mouth, you may need 10 the hand supporting (hethe chin pull back patient's lip.

Doofofnot your thumb into Ihelopatient's mouth (to avoidlower being bitten). supporting (heIhe chin lo pull pullmouth back the patient's lower lip. Do Donot notinsert insert The head-illt, chin-lift maneuver uses head position to align the structures of the airway and provide for supporting (he chin lo back the lower lip. your thumb into patient's (to patient's avoid being bitten). your thumb thumb into into Ihe Ihepatient's patient'smouth mouth(to (toavoid avoidbeing beingbitten). bitten). your the free passage of air. By moving the jaw in an anterior fashion, the tongue is drawn forward, clearing the

Head-Tilt, Chin-Lift Maneuver

PRINCIPLES OF EMT CLINICAL PRACTICE

airway, and with it the tissues of the larynx are moved off the glottic opening.

NOTE:

To perform the head-tilt, chin-lift maneuver,



follow these issteps: The jaw-thrust maneuver the only recommended airway procedure for a unconscious patients with possible head, neck, or spine injury or unknown 1. Once the patient is supine, place one hand on mechanism of injury.



The purpose of the jaw thrust maneuver is to open the airway without movhand under the bony area at the center of the ““ ing the head or neck.

the forehead and place the fingertips of the other

“ patient’s lower jaw.

2. Tilt the head by applying gentle pressure to the patient’s forehead.

Jaw-Thrust Maneuver 3. Use your fingertips to lift the chin and to The jaw-thrust maneuver is most commonly used to open the airway of an unsupport the lower jaw. Move the jaw forward to a conscious patient with suspected head, neck or spine injury or unknown mechapoint where the lower teeth arc almost touching nism of injury. the upper teeth. Do not compress the soft tissues Follow these steps: under the lower jaw. which can obstruct the 1. Carefully keep the patient's head. neck, and spine aligned, moving him as aairway. unit as you place him in the supine position.

2. 4.

Kneel al the top of ihe patient's head. For long-term comfort it may be Do not allow the patient’s mouth to he closed. helpful to rest your elbows on the same surface as the patient's head.

To provide an adequate opening at the mouth, 3. Carefully reach forward and gently place one hand on each side of the patient's lower jaw, at the angles of the jaw below the ears. you may need 10 use the thumb of the hand 4. Stabilize the patient's head with your forearms. supporting the chin lo pull back the patient’s 5. Using your index fingers, push the angles of the patient's lower jaw lower lip. Do not insert your thumb into Ihe forward.

6. Youpatient’s mouth (to avoid being bitten). may need to retract the patient's lower lip with your thumb to keep 7.

the mouth open Do not tilt or rotate the patient's head.

Jaw-Thrust Maneuver The jaw-thrust maneuver is most commonly used to open the airway of an unconscious patient with suspected head, neck or spine ²²Limmer (Brady) Limmer (Brady) ² Limmer (Brady) ³³Pollack, (AAOS) ² Limmer (Brady) Pollack, (AAOS) ³injury or unknown mecha-nism of injury.

Pollack, (AAOS) ⁴ NHTSA

⁴ NHTSA Pollack, (AAOS) ⁴ ³NHTSA ⁴ NHTSA

Follow these steps:

1. Carefully keep the patient’s head. neck, and spine aligned, moving him as a unit as you place him in the supine position.

2. Kneel al the top of ihe patient’s head. For long term comfort it may be helpful to rest your elbows on the same surface as the patient’s head.

3. Carefully reach forward and gently place one hand on each side of the patient’s lower jaw, at the angles of the jaw below the ears.

• The jaw-thrust maneuver is the only 4. Stabilize the patient’s head with your forearms.

In addition torecommended airway procedure for a physically opening the airway with the head-lilt, chin-lift or the jawthrust maneuver, it is imperative (hat (he airway also be cleared of any secretions, 5. Using your index fingers, push the angles of the patient’s lower jaw unconscious patients with possible head, neck, blood, or vomitus.

The most effective way to clear the patient's airway is with a or spine injury or unknown mechanism of injury. unit he forward. wide-bore, rigid-tip hankuer suction device, It is crucial that a suction 6. You may need to retract the patient’s lower lip with your thumb to ready for• immediate use when opening and maintaining the airway. The equipThe purpose of the jaw thrust maneuver is to open ment and techniques used for suctioning will be discussed later in this chapter. keep the mouth open the airway without mov-ing the head or neck.

7. Do not tilt or rotate the patient’s head.

NOTE:

In addition to physically opening the airway with the head-lilt, chin-lift or the jaw-thrust maneuver, it is imperative that the airway also be cleared of any secretions, blood, or vomitus. The most effective way to clear the patient’s airway is with a wide-bore, rigid-tip hankuer suction device, It is crucial that a suction unit he ready for immediate use when opening and maintaining the airway. The equip-ment and techniques used for suctioning will be discussed later in this chapter.

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

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AIRWAY ADJUNCTS If you determine that your patient does not have a patent airway, you must take action to secure it. The airway must be maintained throughout all care proce-dures.

The most common impediment to an open airway is a lack of airway muscle tone. When a patient becomes unconscious, the muscles relax. The tongue and tissues of the larynx will slide back into the pharynx and obstruct the airway. Even though a head-tilt, chin-lift or jaw-thrust maneuver will help open a patient’s airway, the obstruction may resume once the maneuver is released. Some-times even when the head-lilt, chin-lift or jaw-thrust is maintained, soft tissues and the tongue may continue to partially obstruct the airway.

Airway adjuncts, devices that aid in maintaining an open airway, may be used to initially assist in the opening of an airway and continually used to help keep an airway open.

There are several types of airway adjuncts.

The two most common airway adjuncts, whose main function is to keep the tongue from blocking the airway, are the oropharyngeal airway (also known as the oral airway or OPA) and the nasopharyngeal airway (also known as the nasal airway or NPA). The structure and use of these airways can be understood by analyzing their names Oro refers to the mouth, naso the nose, and pharyngeal the pharynx.

Oropharyngeal airways are inserted into the mouth and help properly position the tongue. Nasopharyngeal airways are inserted through the nose and rest in the pharynx, also to help properly position the tongue.

Oropharyngeal Airway Once a patient’s airway is opened, an oropharyngeal airway can be inserted to help keep it open. An oropharyngeal airway is a curved device, usually made of plastic, that can be inserted into the patient’s mouth. Oropharyngeal airway has a flange that will rest against the patients lips. The rest of the device moves the tongue forward as it curves back to the pharynx.

There are different sizes of oropharyngeal airways.

Many manufacturers make a complete line, ranging from airways for infants to large adult sizes. An entire set should be carried to allow for quick, proper selection.

The airway adjunct cannot be used effectively unless you select the correct airway size for the patient.

To determine the appropriate size oral airway, measure the device from the corner of the patient’s mouth to the tip of the earlobe on the same side of the patient’s face.

An alternative method is to measure from the center of the patient’s mouth to the angle of the lower jaw bone.

Do not use an airway device unless you have measured it against the patient and verified it as being the proper size. Remember that if an airway is too big. its distal tip will rest close to the esophagus and direct air into the stomach. If it is too small, it will not properly displace the tongue forward to open the airway. If the airway is not the correct size, do not use it on the patient.

Rules for Using Airway Adjuncts Some rules apply to the use of oropharyngeal and nasopharyngeal airways: • Only use an oropharyngeal airway on patients who do not exhibit a gag reflex. The gag reflex causes vomiting or retching when something is placed in the pharynx. When a patient is deeply unconscious, the gag reflex usually disappears out may reappear as a patient begins to regain consciousness. A patient with a gag reflex who cannot tolerate an oro-pharyngeal airway may he able to tolerate a nasopharyngeal airway.

• Open the patient’s airway manually before using an adjunct device.

• When inserting the airway, lake care not to push the patient’s tongue into the pharynx.

• Have suction ready prior to inserting any airway.

• Do not continue inserting the airway if the patient begins to gag. Continue to maintain the airway manually and do not use an adjunct device. If the patient remains unconscious for a prolonged time, you may later attempt to insert an airway to determine if the gag reflex is still present.

• When an airway adjunct is in place, you must maintain the head-lilt, chin-lift or jaw-thrust maneuver and monitor the airway.

• After an airway adjunct is in place, continue to be ready to provide suction if the gag reflex returns.

• If the patient regains consciousness or develops a gag reflex, remove the airway immediately.

• Use infection control practices while maintaining the airway. Wear disposable gloves, in airway maintenance, there is a chance of a patient’s body fluids coming in contact with your face and eyes. Wear a mask and goggles or other protective eyewear to prevent this contacts.

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NOTE

UNIT 3 DAY 12 To insert an oropharyngeal airway, follow these steps: 1. Place the patient on his back and use an appropriate manual method to open the airway. If no spinal injuries are suspected, use a head-tilt, chin-lift maneuver. If there are possible spinal injuries, use the jaw-thrust maneuver, moving the patient no more than necessary to ensure an open airway (the airway takes priority over the spine).

2. Perform a crossed-finger technique to open the mouth. That is, cross the thumb and forefinger of one hand and place them on the upper and lower teeth at the corner of the patients mouth. Spread your fingers apart to open the patient’s jaws.

3. Position the airway device so that its tip is pointing toward the roof of the patient’s mouth.

4. Insert the device and slide it along the roof of the patient’s mouth, past the soft tissue hanging down from the hack (the uvula), or until you meet resistance against the soft palate. Be certain not to push the patient’s tongue hack into the pharynx. Any airway insertion is made easier by using a tongue blade (tongue depressor) or a rigid suction tip to assist in moving the tongue forward. In a few cases, you may have to use a tongue blade to hold the tongue in place.

Watch what you are doing when inserting the airway.

This procedure should not be performed by “feel” only.

5. Gently rotate the airway 180 degrees so that the tip is pointing down into the patients pharynx.

This method prevents pushing the tongue back.

Alternatively, insert the airway with the lip already pointing “down” toward the patient’s pharynx, using a tongue depressor or rigid suction tip to press the tongue down and forward to avoid obstructing the airway. This is the preferred method for airway insertion in an infant or child. “ 6. Position the patient. Place the nontrauma patient in a head-tilt position. If there are possible spine injuries, maintain cervical stabilization at all times during airway management.

7. Check to see that the flange of the airway is against the patient’s lips. If the airway device is loo long or too short, remove it and replace it with the correct size.

8. Monitor the patient closely. If there is a gag reflex, remove the airway adjunct at once by following the anatomical curvature. You do not need to rotate the device when removing it.

NOTE: Some EMS systems allow an oropharyngeal airway to be inserted with the tip pointing to the side of the patient’s mouth. The device is then rotated 90 degrees so that its tip is pointing down the patient’s pharynx. Use this approach only if it is part of the protocol of your EMS system.

Some EMS systems allow an orophary PRINCIPLES OF EMT CLINICAL PRACTI pointing to the side of the patient's mo

so that its tip is pointing down the patie part of the protocol of your EMS system

Nasopharyngeal Airway Nasopharyngeal Airway

NOTE

The nasopharyngeal airway has gained popularity because

Some EMS systems allow an oropharyngeal airway to he inserted The nasopharyngeal airway has with gaine it often does not stimulate the gag reflex. This allows the pointing to the side of the patient's stimulate mouth. The device is then rotated 90 th d the gag reflex. This allows nasopharyngeal airway to be used in patients who have a reduced so that its tip is pointing down the patient's pharynx.

Use this approach onlr patients who have a reduced level of level of responsiveness hut still have an intact gag reflex. Other part of the protocol of your EMS system. reflex. Other benefits include the fact

benefits include the fact that it can he used when the teeth are clenched and w hen there arc oral injur clenched and w hen there are oral injuries.

Use the soft flexible nasal airway and not the rigid clear Nasopharyngeal Airway Use the soft flexible nasal! airway and plastic airway in the field. The soft ones are less likely to cause field. The soft ones are less likely to ca soft-tissue damage or weeding.

The nasopharyngeal airway has gained popularity because it often doe

typical sizes for adults are 34, 32, 30 and stimulate the gag reflex. This allows the nasopharyngeal airway to be u patients who have a reduced level of hut still have an intac To responsiveness insert a nasopharyngeal airway, follo To insert nasopharyngeal airway, follow these steps: reflex.

Other abenefits include the fact that it can he used when the tee 1. Measure the nasopharyngeal 1. Measure the nasopharyngeal airway from the patient’s nostril clenched and w hen there arc oral injuries. of the ear lobe or to the angle to the tip of the ear lobe or to the angle of the jaw. Choosing will ensure an appropriate diam Usethe correct length will ensure an appropriate diameter. the soft flexible nasal! airway and 2. not Lubricate the rigid clear plastic of airway the outside the l field.

The soft ones are less likely to cause soft-tissue damage or a Weeding 2. Lubricate the outside of the lube with a water-based lubricant insertion. Do not use petrole typical sizes for adults are 34, 32, 30 and 28 French. before insertion. Do not use a petroleum jelly or any other based lubricant. Such substan type of non water based lubricant. Such substances can nasal cavity and the pharynx a To insert a nasopharyngeal airway, follow steps: 3. these Gently push the tip of the no damage the tissue lining of the nasal cavity and the pharynx 1.

Measure the nasopharyngeal airway from the patient's nostril to t neutral position.

Most nasop and increase the risk of infection of the ear lobe or to the angle of the jaw. in Choosing correct placed the rightthe nostril.

Thel 3. Gently push the tip of the nose upward. Keep the patient’s will ensure an appropriate diameter. point toward the base of the head in a neutral position. Most nasopharyngeal airways are 2. Lubricate the outside of the lube with a water-based lubricant b separates the nostrils). designed to be placed in the right nostril. The bevel (angled insertion. Do not use a petroleum jelly or the anyairway other type of 4.

Insert into thenon-w nos portion at the tip) should point toward the base of the nostril based lubricant. Such substances can damage the tissue liningth flange rests firmly against or toward the septum (wall that separates the nostrils). nasal cavity and the pharynx and increase the risk of infection pharyngeal airway.

If you exp 4. Insert the airway into the nostril. Gently advance the airway 3. Gently push the tip of the nose upward.

Keep the and patient's hea pull the lube out try the ot “ until the flange rests firmly against the patient’s nostril. neutral position. Most nasopharyngeal airways are designed Never force a naso-pharyngeal airway. If you experience placed in the right nostril. The bevel (angled portion at the tip) s difficulty advancing the airway, pull the lube out and try the point toward the base of the nostril or toward the septum (wa other nostril. separates the nostrils).

4.

Insert the airway into the nostril. Gently advance the airway un Oropharyngeal and flange rests firmly against the patient's nostril. Never force a nasopharyngeal airways can be a pharyngeal airway. If you experience difficulty advancing the a tremendous asset to the EMT when pull the lube out and try the other nostril.

used properly. However, no device can replace the EMT. The proper use of these airways or any other device depends on the appropriate use, good judgment, and adequate monitoring of the patient by the EMT. Oropharyngeal and nasopharyngeal airways help move soft tissue of the upper airway to provide clear passage for air. To ensure an open airway to the level of the lungs, it is sometimes necessary to insert an endotracheal (through-thetrachea) tube. Endotracheal intubation Do not use a is an advanced life-support procedure nasopharyngeal airway in which EMTs may assist advancedif clear (cerebrospinal) (Brady) level providers. Further more, some ³² Limmer fluid is coming from Pollack, (AAOS) ⁴ NHTSA EMS systems allow for the use of blind the nose or ears. This insertion airway devices. may indicate a skull fracture where the airway would pass.

NOTE:

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

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SUCTIONING

The patient’s airway must be kept clear of foreign materials, blood, vomit us, and other secretions. Materials that are allowed to remain in the airway may be forced into the trachea and eventually into the lungs.

This will cause complications ranging from severe pneumonia to complete airway obstruction. Suctioning is the method of using a vacuum device to remove such materials. A patient needs to be suctioned immediately when fluids or secretions are present in the airway or whenever a gurgling sound is heard.

Suctioning Devices

Each suction unit consists of a suction source, a collection container for materials you suction, tubing, and suction tips or catheters. Systems are either mounted in the ambulance or are portable and may be brought to the scene.

Mounted Suction System Many ambulances have a suction unit mounted in the patient compartment.

These units arc usually installed near the head of the stretcher so they are easily used. Mounted systems, often called “onboard” units, create a suctioning vacuum produced by the engine’s manifold or an electrical power source. To be effective, suction devices must furnish an air intake of at least 30 liters per minute at the open end of a collection tube. This will occur if the system can generate a vac-uum of no less than 300 mmHg (millimetres of mercury) when the collecting tube is clamped.

Portable Suction Units

There are many different types of portable suction units. They may be oxygen or air powered, electrically powered (by batteries or household current), or manually operated. The requirement for the amount of suet ion a portable unit must provide is identical to that of the fixed unit (30 liters per minute, 300 mmHg). It is important to have the ability to suction anywhere. Portable suction devices provide that ability.

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RESPIRATION AND ARTIFICIAL VENTILATION The attached to a suction unit must be thick walled, nonkinking. wide bore tubing. This is because the tubing must not collapse due to the suction, must allow “chunks” of suctioned material to puss and must not kink, which would reduce the suction. The tubing must be long enough lo reach comfortably from suction unit to patient.

Currently, the most popular type of suction tip is the rigid pharyngeal tip. Also called “Yankauer,” “tonsil sucker,” or “tonsiltip” suction. This rigid device allows you to suction the mouth and pharynx with excellent control over the distal end of the device. It also has a larger bore than flexible catheters. Most successfully used with an unresponsive patient, rigid tip suction must be used with caution, especially if the patient is not completely unresponsive or may be regaining con-sciousness. When the tip is placed into the pharynx, the gag reflex may be activated, producing additional vomiting. It is also possible lo stimulate the vagus nerve in the back of the pharynx, which can slow the heart rate. Therefore, be careful not to suction more than a few seconds at a time with a rigid tip and never lose sight of the tip.

Suction catheter* are flexible plastic tubes. They come in various sizes identified by a number “French.”The larger the number, the larger the catheter. A “14 French catheter is larger than an “8 French” catheter.

These catheters are usually not large enough to suction vomitus or thick secretions and may kink. Flexible catheters are designed to be used in situations when a rigid tip cannot be used. For example, a soft catheter can be passed through a tube such as a nasopharyngeal or endotracheal tube or used for suctioning the nasopharynx. (A bulb suc-tion device may also be used to suction nasal passages.)

Another important part of a suction device is the collection container. All units should have a nonbreakable container to collect the suctioned materials. These containers must be easily removed for disposal or decontamination. Remember to wear gloves, protective eyewear, and a mask not only while suctioning but also while cleaning the equipment. Most modem suction devices have disposable containers to eliminate the lime and risks involved in decontamination.

Suction units also must have a For suctioning to container of clean (preferably sterile) be effective, the proper water nearby. The water is used to clear equipment must he mailer that is partially blocking the used. Although a suction tubing. When this partial blockage of unit might be the most the tube occurs, place the suction tip powerful available, it or catheter in the container of water. will do no good unless This will cause a stream of water lo flow used with the proper through the tip and tubing, usually attachments. Before forcing the clog to dislodge. When the tip operating a suction unit, or tubing becomes clogged with an item you must have: that will not dislodge, replace it with a • Tubing new tip or tubing.

• Suction lips In the event of copious, thick • Suction catheters secretions or vomiting, consider • Collection container removing the rigid tip or catheter and • Container of clean using the large bore, rigid suction tubing. or sterile water After you are finished, place the standard tip back on for further suctioning.

Tubing. Tips, and Catheters

Techniques of Suctioning Although there may be some variations in suction technique a few rules always apply. The first rule is always use appropriate infection control practices while suctioning. These practices include the use of protective eyewear, mask and disposable gloves.

Proper suctioning requires you to have your fingers around and sometimes inside the patient’s mouth.

Disposable gloves prevent contact between the EMT and the patient’s bodily fluids. Protective eyewear and mask are also recommended since these fluids might splatter, or the patient may gag or cough, sending droplets to your face, eyes and mouth.

The second rule is to try limiting suctioning to no longer than 10 seconds at a time. This is because prolonged suctioning will cause hypoxia and, potentially, death. If the patient continues to vomit longer than 10 seconds, however, you must still continue to suction. Ventilating foreign mailer into the lungs will also cause hypoxia and possible death.

In short, suction quickly and efficiently for as short a time as possible.

Patients who need airway control and suctioning are often unconscious and may be in cardiac or respiratory arrest. Oxygen delivery to this patient is very important. During suctioning, the ventilations or other methods of oxygen delivery are discontinued to allow for the passage of the suction catheter.

To prevent critical delays in oxygen delivery, limit suctioning to a few seconds, then resume ventilations or oxygen delivery.

In a few cases you will preoxygenate a patient before suctioning. This means that you will adequately ventilate the patient with supplemental oxygen before suctioning, because oxygen levels will drop during suctioning: for example, during routine suctioning of an endotracheal tube. If you come upon a patient with vomitus or other materials in his airway, or if a patient vomits suddenly .and unexpectedly, you should suction immediately, without preoxygenation.

In these cases, preoxygenation would force foreign substances into the lungs, which can be fatal.

The third rule for suctioning is place the tip or catheter where you want to begin the suctioning and suction on the way out. Most suction tips and catheters do not produce suction at all times. You have to start the suctioning. The tip or catheter will have an open distal end where the suction is delivered.

It will also have an opening, or port, in the proximal portion. When you put your finger over the proximal port, suctioning begins from the distal end.

It is not necessary to measure when using a rigid tip. Rather, you should be sure not to lose sight of the tip when inserting it However, do measure the suction catheter in a manner similar to an oropharyngeal airway. The length of catheter that should be inserted into the patient’s mouth is equal to the distance between the corner of the patient’s mouth and earlobe.

Carefully bring the tip of the catheter to the area where suctioning is needed. Never “jab” or force the suction tip into the mouth or pharynx. Then place your finger over the proximal opening to begin the suctioning, and suction as you slowly withdraw the tip from the patient’s mouth, moving the lip from side to side.

Suctioning is best delivered with the patient turned on his side. This allows gravity to assist suction as free secretions will flow from the mouth while suctioning is being delivered. Caution must be used in patients with suspected neck or spine injuries.

If the patient is fully and securely immobilized, the entire backboard may be tilled to place the patient on his side. For the patient for whom such injuries are suspected hut who is not immobilized, suction the best you can without turn-ing the patient. If all other methods have failed, as a last resort you may turn the patient’s body as a unit, attempting to keep the neck and spine in line. Suctioning should not be delayed lo immobilize a patient ll may also he beneficial to manually remove large particles prior to or during suctioning. As always, caution should be taken in placing your fingers in a patient ‘s mouth. However, a shallow sweep will often help remove particles not able to be suctioned through the lu-men of the suction device.

The rigid suction tip or flexible catheter should be moved into place carefully and not forced. Rigid suction devices may cause tissue damage and bleeding. Never probe into wounds or attempt to suction away attached tissue with a suction device.

Certain skull fractures may actually cause brain tissue to be visible in the pharynx. If this occurs, do not suction near this tissue: limit suctioning lo the mouth Suction devices may also cause activation of the gag reflex and stimulate vomiting. In a patient who already has secretions that need to be suctioned, vomiting only makes things worse. If you advance a suction catheter or rigid suction tip and the patient begins to gag, withdraw the tip to a position that does not cause gagging and begin suctioning

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RESPIRATION AND ARTIFICIAL VENTILATION

KEEPING AN AIRWAY OPEN: DEFINITIVE CARE At times keeping an airway open will exceed the capabilities of the basic EMT. Medications and/or surgical procedures may be necessary to resolve the cause of airway obstruction. As an EMT you should rapidly evaluate and treat airway problems, but a also quickly recognize the need for more definitive care. In some systems definitive care may be an advanced life support intercept. In other systems, definitive care might be the closest hospital. Either way, you must know your local system resources and recognize your capabilities and limitations.

SPECIAL CONSIDERATIONS There are a number of special considerations in airway management: • Facial injuries. Take extra care with the airway when patients have facial injuries. Because the blood supply to the face is to rich, blunt and penetrating injuries to the face frequently result in severe swelling or bleeding that may block or partially block the airway. Frequent suctioning may be required. Insertion of an airway adjunct of endotracheal tube may be necessary.

• Obstructions. Many suction units are not adequate for removing solid objects like teeth and large particles of rood or other foreign objects. These must be removed using manual techniques for clearing airway obstruct ions, such as abdominal thrusts, chest thrusts. or finger sweeps, which you learned in your basic life support course and which reviewed in “Basic Cardiac Life Support Review.” You may need to log roll the patient into a supine position to clear the oropharynx manually.

• Dental appliances. Dentures should ordinarily be left in place during airway procedures. Partial dentures may become dislodged during an emergency. Leave a partial denture in place. if possible, but be prepared to remove it if it endangers the airway.

PEDIATRIC NOTE These are several special considerations that you must Luke into account when managing the airway of an infant or child:

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Anatomic Considerations • The mouth and nose of infants and children are smaller and more easily obstructed than those of adults.

• In infants and children, the tongue takes up more space proportionately in the mouth than in adults.

• The trachea (windpipe) is softer and more flexible in infants and children.

• The trachea is narrower and is easily obstructed by swelling.

• The chest wall is softer, and infants and children tend to depend more on their diaphragm for breathing.

Sa trabaho mo bilang EMT, may magiging pasyente ka na nahihirapang huminga pero nakakahinga naman nang husto. Bigyan ito ng oxygen at suriing mabuti bago dalhin sa ospital. Meron namang mga pasyente na mas malubha ang sitwasyon. Hirap na hirap itong huminga at kinakapos na ng hangin.

Kailangang matutunan mo kung kelan “adequate” o sapat ang paghinga at “inadequate” o kulang ang paghinga ng iyong pasyente.

Management Considerations • Open the airway gently. Infants can be placed in a neutral neck position and children only require slight extension of the neck Do not hyperextend the neck, because it may collapse the trachea.

• An oral or nasal airway may be considered when other measures fail to keep the airway open.

• In suctioning infants and children, use a rigid tip but be careful not to touch the back of the airway.

“

PREHOSPITAL EMERGENCY CARE

“

UNIT 3 DAY 12

RESPIRATION Respiratory Anatomy and Physiology

3 2

To get through this chapter easily, you should make sure you are familiar with the following structures of the respiratory system: nose, mouth, oropharynx, nasopharynx, epiglottis, trachea, cricoid cartilage, larynx, bronchi, lungs, alveoli, and diaphragm.

The diaphragm is a muscular structure that separates the chest cavity from the abdominal cavity. During a normal respiratory cycle, the diaphragm and other parts of the body work together to allow the body to inhale (breathe in) and exhale (breathe out) air.

PRINCIPLES OF EMT CLINICAL PRACTICE

UNIT 3 DAY 12

PRINCIPLES OF EMT CLINICAL PRACTICE

 Inspiration. The active process that

uses the contraction of several The size respiratory muscles to increase the of the cycle chest cavity is called inspiration. In • Inspiration. active process this process, the The intercostal (rib)that The active process Inspiration. the contraction ofconseveral muscles uses and the diaphragm that uses the contraction of muscles to increase the size of the tract. The diaphragm lowers and several muscles to increase the chest cavity is called inspiration. In the ribs this move upward and out-(rib) size of the chest cavity is called process, the intercostal inspiration. In this process, the ward. The expanding of theconmuscles and the size diaphragm intercostal (rib) muscles and chest cavity then air to (lowand tract.

The causes diaphragm lowers the diaphragm contract. The ribs move upward into the the lungs.

Another termand foroutdiaphragm lowers and the ribs ward.

The expanding size of the inspiration is inhalation.

progresses as follows:

chest cavity then causes air to (low move upward and out-ward. into the lungs. Another term for The expanding size of the chest inspiration is inhalation. cavity then causes air to (low

into the lungs. Another term for inspiration is inhalation.

 Expiration. A passive process, expi-

ration involves the relaxation • Expiration.

A passive process, Expiration.

A passive process,ofexpiexpi-ration involves the the rib ration muscles and the diaphragm. involves relaxation of relaxation of the rib muscles rib muscles and diaphragm.

The ribsthemove downward and Theand diaphragm. The ribs ribs downward inward, while themove diaphragm rises.and inward, while the diaphragm rises. move downward and inward, This movement causes the chest This movement causes the chest while the diaphragm rises. cavity tocavity decrease in size andand to decrease in size This movement causes the causes air to flow out of the lungs. causes air to flow out of the lungs. chest cavity to decrease in size term for expiration is exAnother Another term for expiration is exand causes air to flow out of halation,halation, the lungs. Another term for

REVIEW IN TOPIC How oxygen and carbon dioxide are exchanged through the alveoli and capillaries of the lungs, and through the capillaries and cells throughout the body. The exchange of oxygen and carbon dioxide, both in the lungs and in the body’s cells, is critical to support life.

There are many things that can go wrong within the body that will alter this vital exchange.

Primarily, these are problems with the respiratory system or the circulatory system, as were described in Chapter “Principles of Pathophysiology.” This chapter will further discuss the respiratory system as well as problems with breathing and their effects on the body.

expiration is exhalation.

Review in topic "Medical Terminology and Anatomy and Physiology." how oxyand "Medical carbon dioxide are exchanged the alveoli and capillarieshow of theoxyReview ingen topic Terminology andthrough Anatomy and Physiology." and throughare theexchanged capillaries and cells throughout the body.

The exchange gen and lungs, carbon dioxide through the alveoli and capillaries of the of oxygen and carbon dioxide, both in the lungs and in the body's cells, is critical lungs, and through the capillaries and cells throughout the body. The exchange to support life. There are many things that can go wrong within the body that of oxygenwill and carbon dioxide, both in the these lungsare and in the with body's is critical alter this vital exchange.

Primarily, problems thecells, respiratory to support life. There are manysystem, things asthat can go wrong within"Principles the bodyofthat system or the circulatory were described in Chapter This chapter will further the respiratory as well will alter Pathophysiology." this vital exchange.

Primarily, thesediscuss are problems withsystem the respiratory as problems with breathing and their effects on the body.

Problems with (he of system or the circulatory system, as were described in Chapter "Principles circulatory system will be discussed in greater detail in topic "Cardiac EmergenPathophysiology." This chapter will further discuss the respiratory system as well

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other. When observing the chest cavity, both sides should and adequately to indicate a proper air exchange, the de pirations must be adequate.

RESPIRATION AND ARTIFICIAL VENTILATION Inadequate Breathing

Day 12

Inadequate breathing is breathing that is not sufficient to suppor treated, this condition will surety lead to death. One of your most i as an EMT is to identify and treat patients with inadequate breat early in the call and continue them th Breathing adequately doesn’t need an sessment and treatment Inadequate breathing is breathing that is not sufficient Patients who are breathing adequately at fir instruction manual. We do not consciously lime with the patient. to support life. If left untreated, this condition will surely have to tell ourselves to inhale and exhale. The lead to death. One of your most important tasks as an rate into inadequate breathing later on.

Adequate Breathing

Inadequate Breathing

brain does that automatically. Breathing may be classified as adequate or inadequate. Simply stated, adequate breathing is breathing that is sufficient to support life. Inadequate breathing is not. Your assessment of the adequacy of a patient’s breathing may be vital to his survival.

Adequate breathing falls within certain ranges that are considered “normal.”The patient will not appear to be in distress. He will be able to speak full sentences without having to catch his breath.

His color, mental status, and orientation will he normal. Normal breathing may he determined by observing for rate, rhythm, and quality:

EMT is to identify and treat patients with inadequate breathing. Begin assessment and treatment early in the call and continue them throughout your lime with the patient. Patients who are breathing adequately at first may deteriorate into inadequate breathing later on.

Inadequate Breathing

• Rate. Rates of breathing that are considered normal vary by age. For an adult, a normal rate is 12-20 breaths per minute. For a child, it is 15-30 breaths per minute. For an infant, it is 25-50 breaths per minute.

• Rhythm. Normal breathing rhythm will

usually be regular. Breaths will be taken at regular intervals and will last for about the Decision Making Points same length of time. Remember that talking and other factors can make normal breathing slightly irregular.

• Is the patient breathing'

• Is the patient breathing ade• Quality. Breath sounds, when auscultated quately' with a stethoscope, will normally be present • Do I haveand equal when the lungs are compared an intervention to to each other. When observing the chest help this patient' cavity, both sides should move equally • Will this patient benefit from and adequately to indicate a proper air exchange. The depth of the respirations ALS? must be adequate.

Inadequate Breathing PATIENT ASSESSMENT

• Cool clammy skin • Tripod position • Retractions • Fast or slow

If the patient is not breathing adequately 10 support life, • Irregular rhythm

respiratory rate • Increased effort to breathe • Cyanosis following conditions • Use of accessory muscles • Shallow breaths



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you may

Rate. The patient with inadequate breathing will have a that is out of the normal ranges Very slow breaths a breaths may not allow enough an to enter the lungs, r enough oxygen being distributed throughout the body. tions (also called dying respirations) are sporadic, irregul are usually seen just before respiratory arrest They ar gasping with only a few breaths per minute This breat clearly a sign of inadequate breathing

d move equally epth of the res-

rt life. If left unimportant tasks thing. Begin asIf the patient is not breathing adequately to support hroughout your life, you may see any of the following conditions rst may deterio-

PATIENT ASSESSMENT

• Rate. The patient with inadequate breathing will

have a breathing rate that is out of the normal ranges. Very slow breaths and very rapid breaths may not allow enough air to enter the lungs, resulting in not enough oxygen being distributed throughout the body. Agonal respirations (also called dying respirations) are sporadic, irregular breaths that are usually seen just before respiratory arrest. They are shallow and gasping with only a few breaths per minute This breathing pattern is clearly a sign of inadequate breathing.

• Rhythm. The rhythm of inadequate breathing

may be irregular However, rhythm is not an absolute indicator of adequate or inadequate breathing. Remember that someone who is talking or is awake that you are observing his respirations may have slight irregularities, even though his breathing is adequate. However, a patient may have a regular late, even when his breathing is inadequate

• Quality. When breathing is inadequate, breath

sounds may be diminished or absent. The depth of respirations (tidal volume) will be inadequate or shallow. Chest expansion may be inadequate oirunequal and respiratory effort increased You may note the use of accessory muscles (e.g., muscles of the neck and abdomen) in breathing Since oxygenation of the body’s tissues is reduced, the skin may be pale or cyanotic (blue) and feel cool and clammy to the touch. In patients with dimin-ished responsiveness, sounds such as snoring and gurgling also indicate a serious airway problem that tequilas immediate intervention.

y see any of the

a breathing rate and very rapid resulting in not Agonal respiralar breaths that re shallow and thing pattern is

PEDIATRIC NOTE Respiratory problems can be very serious in infants and children. Although children rarely have heart attacks or other problems of adulthood, respiratory conditions are a leading killer of infants and children With this in mind, you must beg in respiratory treatment of infants and children with a thorough and accurate assessment and prompt, proper care.

The structure of infants’ and children’s airways differs somewhat from that of adults • Airway. Airway structures are smaller in an infant or child than in an adult and therefore are more easily obstructed.

• Tongue. Infants’ and children’s tongues are proportionately larger and therefore take up more space in the mouth than an adult’s tongue.

• Trachea. The trachea is smaller, softer, and more flexible in infants and children, which may load to obstruction from swelling or trauma mote easily than in adults The cricoid cartilage is less developed and less rigid.

• Diaphragm. Infants and children depend more heavily on the diaphragm for respiration since the chest wall is softer. This is why infants and small children in respiratory distress exhibit “seesaw breathing” in which the movement of the diaphragm causes the chest and abdomen to move in opposite directions.

Be aware that some signs of inadequate breathing are unique to or more promi-nent in infants und children. Therefore, be on the lookout for these signs: • • • •

Nasal flaring (widening of the nostrils) Grunting Seesaw breathing Retractions (pulling in of the muscles) between the rib* (intercostal), above the clavicles (supraclavicular), and above the sternum (suprasternal)

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PRINCIPLES OF EMT CLINICAL PRACTICE

PATIENT CARE

Inadequate Breathing There is a wide range of function between adequate respirations and complete stoppage of breathing (respiratory arrest). You must pay careful attention to the patient s breathing throughout the call. It is not enough to simply make sure he is breathing. The patient must be breathing adequately. If at any time you find that he is not breathing adequately, the treatment of this condition is your first patient-care priority.

When you determine, by the signs that were discussed under the previous Patient Assessment feature, that a patient’s breathing is inadequate, you will provide assisted ventilation with supplemental oxygen. In order of preference, the means of providing assisted ventilation are: 1. Pocket face mask with supplemental oxygen.

2. Two-rescuer bag valve mask with supplemental oxygen.

3. Flow restricted, oxygen powered ventilation device.

4. One-rescuer bag-valve mask with supplemental oxygen.

Make sure that you are properly trained with the device that you are using for ventilation. If supplemental oxygen is not immediately available, begin artificial ventilation without supplemental oxygen and attach the oxygen supply to the mask as soon as it is available.

If you are uncertain about whether a patient’s breathing is inadequate and requires artificial ventilation, provide artificial ventilation. In the rare circumstance when a patient with inadequate breathing is conscious enough to fight artificial ventilation, transport immediately and consult medical direction

Adequate and Inadequate Artificial Ventilation Like breathing, artificial ventilation can be adequate or inadequate. When adequate, the chest will rise and fall with each artificial ventilation. The adequate rate for artificial ventilation is 12 breaths per minute for adults and 20 per minute for infants and children.

When you provide artificial ventilation without chest compressions (patient has a pulse), monitor the pulse carefully.

With adequate artificial ventilation, the rate should return to normal or near normal. Since the pulse in adults will usually increase when there is a lack of oxygen, a pulse that remains the same or increases may indicate inadequate artificial ventilation. Naturally, if the pulse disappears this indicate that the patient is in cardiac arrest and needs chest compressions (CPR).

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PEDIATRIC NOTE Pediatric patients differ from adults in many ways. There are few differences that are more important in emergency care than those within the respiratory system. When adult patients experience a decrease in oxygen in the bloodstream (hypoxia), their pulse increases In infants and children with respiratory difficulties, you may observe a slight increase in pulse early, but soon the pulse will drop significantly. A low (or bradycardic) pulse in infants and small children in the setting of a respiratory emergency usually means trouble. This is a sharp contrast from adults where it is a good sign when the pulse lowers to a more normal level.

If you observe a pulse below the expected rates for infants and children, evaluate your ventilations or oxygen therapy thoroughly.

In ventilations, make sure that you have an open airway and that the chest rises with each breath. Nothing is more important for infants and children than adequate airway. In any situation, make sure that the oxygen tank has not run out and that the tubing has not tanked or slipped off the delivery device or oxygen cylinder.

For any patient—adult, child, or infant—if the chest does not rise and fall with each artificial ventilation, or the pulse does not return to normal, increase the face of ventilations. If the chest still does not rise, check that you are maintaining an open airway by the head-tilt-chin-lift maneuver (if there is no suspected spine injury) or by the jaw-thrust maneuver (if spine injury is possible). Insert an oropharyngeal or nasopharyngeal airway as needed to prevent the tongue from blocking the airway.

Suction fluids and foreign matter from the airway as necessary, or perform abdominal thrusts and finger sweeps as needed to clear large airway obstructions. Deliver alternating series of back blows and chest thrusts to clear airway obstructions in infants. Do not perform blind finger sweeps. Remove only visible objects in infants and children. If you are using supplemental oxygen, check that all connections are secure and that the tubing has not kinked.

In infants and children, it is especially important to distinguish between an upper airway obstruction and a lower airway disease if there appears to be a blockage Refrain from placing of the airway. If the airway anything in the patient’s is blocked by the tongue, mouth, administer oxygen, and blood, secretions, or debris, transport as quickly as possible consider suctioning, if you see any signs of a serious performing finger sweeps or respiratory problem such as: inserting an oropharyngeal * Wheezing, stridor, or or nasopharyngeal adjunct grunting to help maintain an open * Increased breathing effort airway. * Flared nostrils or retracted Infants and children muscles of breathing are also subject to * Rapid breathing respiratory infections (e.g. * Pale or cyanotic lips or croup) that may result mouth in swelling of the airway passages. In such cases, probing or placing anything in the patient’s mouth or pharynx may set off spasms along the airway.

BREATHING DIFFICULTY Breathing difficulty is a frequent chief complaint, representing a patient’s feeling of labored or difficult breathing. Although there are objective signs associated with breathing difficulty (as the following text will show), the “difficulty” the patient reports to you is a subjective perception of the patient. The amount of distress the patient feels may or may not reflect the actual severity of his condition. His breathing may be more adequate or less adequate than he feels it is. Therefore, you should not rely entirely on the pattern’s report to decide the seriousness of the condition. Perform an assessment to help you make that determination.

It is important to remember that a patient with breathing difficulty may have either adequate or inadequate breathing. You may encounter two patients, at different times, who tell you that Ihcy are having difficulty breathing (“I can’t catch my breath” or a similar complaint). One patient may he having minor difficulty due to a pre-existing respiratory condition but still have adequate breathing. His condition is not life threatening. The other patient, who has offered exactly the same complaint. may be having a problem such as an allergic reaction and severe difficulty breathing. Your examination of this patient may reveal inadequate breathing that requires immediate artificial ventilation. Difficulty in breathing may have many causes ranging from ongoing medical conditions to illnesses such as pneumonia and other infections, to cardiac problems that cause disturbances in the respiratory system.

PATIENT ASSESSMENT

Breathing Difficulty

The secondary assessment for patients with respiratory emergencies involves an appropriate interview and an examination of the chest and respiratory structures. The OPQRST memory aid is very useful fot gathering a history when the chief complaint is pain, but needs to be adapted when the chief complaint is difficulty breathing:

O — Onset. When did it begin?

P — Provocation. What were you doing when this came on? Have you been short of breath

when exerting yourself?

Q — Quality. Do you have a cough and are you bringing anything up with it?

R — Radiation. Do you have pain or discomfort anywhere else in your body? Does it seem to spread to any other part of your body?

S — Severity. On a scale of 1 to 10, how bad is your breathing trouble? (10 is worst, 1 best) T — Time. How long have you had this feeling?

Associated symptoms Have you noticed any weight gain in the last few days?

Ask if the patient has taken any prescribed medications or done anything else to help relieve his condition. This may affect the treatment provided by you and the treatment provided later at the hospital. After assessing the adequacy of respirations, you should gather vital signs and perform a physical exam focused on the respiratory system This includes the following:

Observing • Altered mental status, including restlessness, anxiety, or depressed level of consciousness • Unusual anatomy (barrel chest) • The patient’s position: • Tripod position (patient leaning forward with hands on knees or another surface) • Sitting with feet dangling, leaning forward • Work of breathing, including: • Retractions • Use of accessory muscles to breathe • Flared nostrils • Pursed lips • The number of words the patient can say without stopping, described as one word dyspnea, two word dyspnea • Pale, cyanotic, or flushed skin • Pedal edema, swelling around the calves, ankles, and feet • Sacral edema, swelling around the low back m bedridden patients • Noisy breathing, which may be described as • Audible wheezing (heard without a stethoscope) • Gurgling • Snoring • Crowing • Stridor (harsh, high-pitched sound during breathing, usually due to uppei airway obstruction) • Coughing

Auscultation

• Lung sounds on both sides during inspiration and expiration

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ing

scles to breathe Day 12

PRINCIPLES OF EMT CLINICAL PRACTICE

ds the patient can say without stopping, ded dyspnea, two-word dyspnea skin ound the calves, ankles, and feet ■ Increased pulse rate ound the low back m bedridden patients ■ Decreased pulse rate (especially in infants and children) ay be described ■ as Changes in the breathing rate (above or below normal heai d w i th out steth levels) oscopo)

Evaluating Vital Sign Changes, Which May Include:

Special Considerations Pulse usually due to pitched soundRegarding during breathing, uction) Oximeter Readings

Topic “Vital Signs and Monitoring Devices,” discussed use of the pulse oximeter to determine the oxygen saturation of the patient’s blood and identify hypoxic patients (patients with less than es during inspiration and expiration adequate oxygenation) Although the other signs and symptoms listed previously are certainly enough to identify hypoxia, the pulse oximeter will allow you to obtain a precise nu-merical reading.

If you have a pulse oximeter immediately ecially in infants and children) available, place the sensor on the patient’s finger before applying oxygen This will give you a ‘room rate {above or below normal levels) air” reading and give you the patient’s saturation thm before you apply oxygen. When you apply oxysion gen to the patient, the reading should improve O2 readingDocument both readings on the report. Never of less than 95 percent on the pulse delay administration of oxygen to obtain a reading.

If the pulse oximeter is not immediately available, apply oxygen immediately and apply the pulse oximeter when it becomes available.

anges, Which May Include:

egarding Pulse Oximeter Readings

ng Dese oxisaturadentify h less hough listed gh to imeter se nu-

Although an oximeter reading between 95 and 100 percent is normal, oxygen should be mediately available, place the sensor on the paadministered to all patients with respiratory ygen This will give you a 'room air" reading and distress regardless of their oxygen saturation before youreadings Even a patient with a saturation reading apply oxygen. When you apply oxyhould improve Document both readings on the of 100 percent should receive oxygen if he has any signs of respiratory distress. on of oxygen to obtain a reading. If the pulse

lable, apply oxygen immediately and apply the available.

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etween 96 and 100 percent is normal, oxygen ients with respiratory distress regardless of their a patient with a saturation reading of 100 per-

■ Changes in breathing rhythm ■ Hypertension or hypotension ■ Oxygen saturation, or SpO2 reading of less than 95 percent on the pulse oximeter

Special Considerations Regarding Auscultation of Lung Sounds When you auscultate the patient’s lungs with a stethoscope, you may hear breath sounds that are normal or diminished in volume You may also hear abnormal sounds such as wheezing, rhonchi, and crackels. Although there is no single universally agreed-upon system for describing these sounds, some of the more common descriptions appear in the following list: • Wheezes are high pitched sounds that will seem almost musical in nature. The sound is created by air moving through narrowed air passages in the lungs. It can be heard in a variety of diseases but is common in asthma and sometimes in chronic obstructive lung diseases such as emphysema and chronic bronchitis.

Wheezing is most commonly heard during expiration.

• Crackles (as the name indicates) are fine crackling or bubbling sounds heard upon inspiration. The sound is caused by fluid in the alveoli or by the opening of closed alveoli. Some people refer to crackles as rales.

• Rhonchi are lower pitched sounds that resemble snoring or rattling. They are caused by secretions in larger airways as might be seen with pneumonia or bronchitis or when materials are aspirated (breathed) into the lungs. The difference between crackles and rhonchi is not always obvious and is somewhat subjective. However, rhonchi generally are louder than crackles.

• Stridor is a high-pitched sound that is heard on inspiration.

It is an upper-airway sound indicating partial obstruction of the trachea or larynx. Stridor is usually audible without a stethoscope.

Listen for these lung sounds on both sides over the patient’s chest (upper and lower), at the mid axillary line, and over the patient’s back (upper and lower). Listening to the lungs in several areas may help to localize the patient’s problem, since some sounds may be present in the lower lobes (e.g. crackles from early congestive heart failure) whereas others may be present throughout the lungs (e.g. wheezes from an asthma attack). You may also observe changes over time when listening to lung sounds.

An asthmatic patient who has used his inhaler may feel that he is breathing easier and the wheezes have diminished. Be careful, however. Sometimes the wheezes will also disappear when a patient worsens and his breathing becomes inadequate. This is because the patient is not moving enough air in and out of the lungs any more to create the wheezing. Although lung sounds can be useful, they are only a rough indicator of what is going on inside the patient’s chest. Only movement or vibrations that are strong enough to be transmitted through the tissue of the chest are audible with your stethoscope. Remember that your patient’s overall status is more important than his lung sounds.

PATIENT CARE

Breathing Difficulty When a patient is suffering from breathing difficulty, provide the following care:

• Assessment. Assess the airway during the primary

assessment and then frequently throughout the call.

Assist respiration with artificial ventilations and supplemental oxygen whenever the patient has or develops inadequate breathing.

• Oxygen. Oxygen is the main treatment for any patient in respiratory difficulty. If the patient is breathing adequately, use a nonrebreather mask at 15 liters per minute to provide oxygen. Use a nasal cannula only in cases where the patient will not tolerate a mask. If the patient has inadequate breathing, provide supplemental oxygen while performing artificial ventilation.

• Positioning. If the patient is experiencing breathing difficulty but is breathing adequately, place him in a position of comfort. Most patients with breathing difficulty feel they can breathe better silting up However, this is not possible if the patient has inadequate breathing, since the patient would need to be supine to receive assisted ventilations • Prescribed inhaler. If the patient has a prescribed inhaler, you may be able to assist the patient in taking this medication This would be done after consultation with medical direction, often during transportation to the hospital.

• Continuous positive airway pressure (CPAP).

Continuous Positive Airway Pressure (CPAP) The use of non-invasive positive pressure ventilation (NPPV) that was commonly available in some EMS system for use in relieving difficulty in breathing, is the continous positive airway pressure (CPAP). It consists of a mask and a means of blowing oxygen or air into the mask at relatively low pressures. Patients with obstructive sleep apnea sometimes have these devices at home and use them at night to prevent the airway from collapsing during sleep.

They are also used in health care settings in some patients with respiratory failure. A CPAP device works through some simple principles: Blowing oxygen or air continuously at a low pressure into the airway prevents the alveoli from collapsing at the end of exhalation and it can also push fluid out of the alveoli back into the capillaries that surround them.

Portable CPAP is relatively new so the indications for its use are evolving. Common uses include pulmonary edema and drowning, in which there is fluid in the alveoli that can be pushed out of the alveoli and hack into the

capillaries; asthma and COPD. in which the alveoli are at risk of closing at the end of exhalation; and in some EMS systems, respiratory failure in general. Contraindications generally fall into two classes: anatomic-physiologic and pathologic. Anatomic-physiologic contraindications include menial status so depressed that the patient cannot protect his airway or follow instructions: lack of a normal, spontaneous respiratory rate (CPAP increases the volume of air the patient breathes, but does not increase the patient’s respiratory rate); inability to sit up; hypotension, generally considered to be less than 90 mmHg: and inability to get and maintain a good mask seal. Pathologic contraindications include nausea and vomiting; penetrating chest trauma, particularly when a pneumothorax is possible: shock; upper gastrointestinal bleeding or recent gastric surgery; and any condition that would present a good mask seal, such as congenital facial malformations, trauma or burns. There are other conditions in which, even though CPAP may not be contraindicated, the EMT nevertheless needs to exercise caution: claustrophobia or inability to tolerate the mask and seal; history of inability to use CPAP; secretions so copious that they need to be suctioned; and a history of pulmonary fibrosis Although CPAP is frequently effective in relieving patients’ difficulty breathing, it has some side effects the EMT needs to be aware of. Since CPAP works by maintaining a positive pressure throughout the respiratory cycle, less blood is able to return to the heart through the veins. Ordinarily, when inspiration occurs, the pressure in the thoracic cavity decreases enough that it promotes the return of blood to the heart. When CPAP is being used, the pressure in the lungs causes less blood to return to the heart, so the cardiac output decreases, frequently resulting in a drop in blood pressure. In some patients, the drop may be enough to make the patient hypotensive.

For this reason, the patient needs to have a systolic blood pressure of at least 90 mmHg. When the lungs are subject to continuous positive pressure, there is a risk that the pressure may cause a weak area to rupture, leading to lung collapse (pneumothorax). This risk is increased in patients with chronic respiratory conditions such as COPD and asthma. However. COPD patients with difficulty breathing are commonly treated with BiPAP in the emergency department.

Patients who are vomiting (or nauseated, putting them at risk of vomiting) have an increased risk of aspiration because positive pressure can push air into the stomach, resulting in gastric distention, This can lead to vomiting and blowing of the vomitus into the airway and lungs.

A less dangerous side effect, though very uncomfortable for the patient, is drying of the corneas of the eyes. Even a small leak at the top of the mask can lead to a high volume of air blowing directly into the eyes, especially if transport time is long Different models of CPAP devices are available. One LIFELINE

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high volume of air blowing directly into the eyes, especially if transport lime is long.

Different models of CPAP devices are available. One uses a battery-powered machine to blow oxygen and air at an adjustable pressure. This has the advantage of using only at much oxygen as the patient needs: however, its disadvantage is that it needs Day 12a charged battery in order to operate. Another model has no machine, but instead uses the Venturi principle. As oxygen goes through specially shaped channels in (he plastic mask, a certain flow rate creates a particular presuses a battery-powered machine to blow oxygen and air before, it may help to allow him to hold the mask sure, Higher flow rates produce higher pressures. This has the advantages of at an adjustable pressure. This has the advantage of using lighter weight and no need for initially. Once he gets used to it and starts to feel some a battery: however, its disadvantage is that it uses only as much oxygen as the patient needs: however, its improvement, you can attach the straps that will hold oxygen quickly.

RESPIRATION AND ARTIFICIAL VENTILATION

disadvantage is that it needs a charged battery in order the mask in place. Start with a low level of CPAP. Many To apply CPAP, explain to the patient that you are applying a mask that is going to operate. Another model has no machine, but instead systems start between 2 and 5 centimeters of water (cm to push air into his lungs. It may feel strange but. within a couple of minutes, he uses the Venturi principle. As oxygen goes through H2O). Reassess the patient’s mental status, vital signs, should feel better. If the patientand level of dyspnea frequently. Raise the level of CPAP has never bad CPAP before, it may help to allow specially shaped channels in the plastic mask, a certain him to hold the mask initially. if there is no relief within a few minutes. If the patient’s Once he gets used to it and starts 10 feel some flow rate creates a particular pressure, Higher flow rates improvement, you can attach the straps that w ill hold the mask in place. Start produce higher pressures. This has the advantages of mental status or respiratory condition deteriorates, with a low level of CPAP. Many systems start between 2 and 5 centimeters of lighter weight and no need for a battery: however, its remove the CPAP and begin ventilating the patient with water (cm H2O). Reassess the patient's mental status, vital signs, and level of disadvantage is that it uses oxygen quickly. a bag mask. dyspnea frequently. Raise the level of CPAP if there is no relief within a few minTo apply CPAP, explain to the patient that you are Follow your local protocols as to when to apply utes. If the patient's mental status or respiratory condition deteriorates, remove applying a mask that is going to push air into his lungs.

CPAP. how much to start with, how frequently to the CPAP and begin ventilating the patient with a bag mask.

It may feel strange but. within a couple of minutes, he increase it, and how high to go. should feel better. If the patient has never bad CPAP Follow your local protocols as to when to apply CPAP. how much to start with, how frequently to increase it, and how high to go.

RESPIRATORY CONDITIONS

“

RESPIRATORY CONDITIONS

Although treatment in the field is very similar for different respiratory diseases,

Although treatment in the field is very similar for different respiratory diseases, the EMT may find it useful to the EMT may find it useful to understand some of the more common causes of understand some of the more common causes of this complaint, along with the signs and symptoms associated with them. this complaint, along with the signs and symptoms associated with them.

Chronic Obstructive Pulmonary Disease (COPD) CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) EMPHYSEMA EMPHYSEMA

Emphysema—as well as Emphysema—as well as chronic chronic bronchi lis, black bronchitis, black lung, and many undeterlung, and many undetermined respiratory illnesses that cause mined respiratory illnesses the patient problems like those seen in that cause the patient emphysema—are all classified as chronic problems like those seen obstructive pulmonary disease (COPD).

PRINCIPLES OF EMT CLINICAL PRACTICE ASTHMA

in emphysema—are all classified as chronic obstructive pulmonary disease (COPD).

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

ASTHMA Seen in young and old patients alike, asthma is a chronic disease that has episodic exacerbations or flares (a disease that only seems to affect the patient at irregular intervals).

This is far different from chronic bronchitis and emphysema, both of which continually afflict the patient. Asthma also differs from chronic bronchitis and emphysema in that it docs not produce a hypoxic drive. An asthma attack or flare can be life threatening. Between episodes, the asthmatic patient can lead a normal life. Many use steroid inhalers for their chronic condition with albuterol administered only for a “rescue” during a flare. Attacks can be precipitated by insect

Seen in young and old patients alike, asthma is a chronic disease that has episodic 304 LIFELINE or flares PREHOSPITAL EMERGENCY CARE exacerbations (a disease that only seems to affect the patient at irregular intervals). This is far different from chronic bronchitis and emphysema, both of which continually afflict the patient. Asthma also differs from chronic bronchitis and emphysema in that it docs not produce a hypoxic drive. An asthma attack or flare can be life threatening. Between episodes, the asthmatic patient can lead a normal life. Many use steroid inhalers for their chronic condition with albuterol

Karamihan ng pasyente stings, air pollutants, infection, na may asthma ay puwedeng and accumulation of fluid in strenuous exercise, or emotional mabuhay nang normal. the abdominal cavity. When stress. When an asthma attack Kailangan lamang nilang the patient lies down at night lo occurs, the small bronchioles iwasan ang mga bagay na sleep, the fluid in the body moves that lead to the air sacs of the nagiging sanhi ng pag-atake back into the circulation. This lungs become narrowed because ng kanilang asthma. means it can easily overload the of contractions of the muscles system and leak into the lungs, that make up the airway. To leading at first to mild dyspnea complicate matters, there is an that can be relieved by sleeping overproduction of thick mucus. propped up on one pillow, then The combined effects of the two pillows or even three pillows. contractions and the mucus At some point, the amount of cause the small passages to fluid becomes too much and the practically close down, severely patient awakens acutely short of breath, with the feeling that restricting air flow. he is drowning. If the patient can speak, he may be able lo The air flow is mainly restricted in one direction. tell you that he has been feeling a little worse each night for When the patient inhales, the expanding lungs exert an the last several days. He may also have noticed a weight gain outward pull, increasing the diameter of the airway and of several pounds in just a few days perhaps accompanied by allowing air to flow into the lungs. During exhalation, the need for a larger belt. Other signs and symptoms include however, the opposite occurs and the stale air becomes anxiety, pale and sweaty skin, tachycardia, hypertension, trapped in the lungs. This requires the patient to exhale respirations that are rapid and labored, and a low oxygen the air forcefully, producing the characteristic wheezing saturation. In severe cases, you may hear a gurgling sound sounds associated with asthma. There is no known way from the lungs, even without a stethoscope, each time the to prevent asthma, but episodes of distress can often be patient breathes. When you auscultate the lungs, you will prevented by use of appropriate medications and careful usually hear crackles or sometimes wheezes. In severe cases, attention to avoiding items that trigger attacks. the patient may cough up frothy sputum, which is usually white but sometimes pink-tinged Treatment includes high concentration oxygen by mask unless the patient’s breathing is inadequate and you need Patients with congestive heart failure (CHF) may to ventilate the patient. If at all possible, keep the patient’s experience difficulty breathing because of fluid that legs in a dependent position (hanging down). Bringing the accumulates in the lungs, preventing them from breathing legs up may push more fluid into the already overloaded adequately. The abnormal accumulation of fluid in the circulatory system and make matters worse. As noted alveoli of the lungs is known as pulmonary edema. It earlier. CPAP may be very useful in these patients since it typically occurs because the left side of the heart has can physically push the fluid back out of the lungs and into been damaged, often by a myocardial infarction (heart the capillaries where it belongs. Although most cases of attack) or chronic hypertension. Since the left side of the pulmonary edema you see will be the result of heart failure heart receives blood from the lungs, the inability to pump or MI, there are some noncardiac causes. Some people, for blood out results in pressure building up and going back example, when exposed to the low atmospheric pressure to the lungs. Since there is only one layer of cells lining of high altitudes, may develop pulmonary edema. In this the alveolus and one layer of cells covering the adjoining case, the heart is fine The most important treatment for capillaries, when pressure builds up. it is relatively easy these patients is to bring them back to normal altitude for fluid to cross this thin barrier and accumulate in the and atmospheric pressure. You should administer highalveoli. If fluid occupies the lower airways, it is difficult concentration oxygen until this can be accomplished for oxygen to reach the blood and the patient experiences Although traditionally called congestive heart failure, this dyspnea. condition is now called simply heart failure to reflect the Patients with CHF often have both left-sided heart reality that many patients don’t develop the congestion failure and right-sided heart failure. Since the right side of (with blood) of the body’s organs. This condition, whatever the heart receives its blood from the systemic circulation it is called, is quite common and is fortunately much more (everything besides the lungs), pressure backs up into treatable than it used to be. Many patients who wouldn’t the systemic circulation. This becomes visible as edema have survived more than a year or two just a decade ago are in the lower parts of the body, typically the lower legs. In now living active lives, thanks to strict diet modification bedridden patients, the legs are not the lowest part of the (low sodium), modern pharmacology, and. in some cases, body. Instead, fluid accumulates in the sacral area of the the use of advanced electronic pacemakers that make the lower back. Sometimes, the CHF patient will also have heart beat more efficiently. jugular vein distention (JVD). bulging of the neck veins,

PULMONARY EDEMA

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PRINCIPLES OF EMT CLINICAL PRAC Day 12

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PNEUMONIA

Prehospital care consists of supportive treatment that you would adm any patient with difficulty breathing, If the pneumonia is thought to be Pneumonia is an infection of one or both lungs caused by bacteria, viruses, or fungi. It results from the inhalation of the patient will receive antibiotics al the emergency department, The certain microbes that grow in the lungs and cause inflammation. People with COPD or other respiratory diseases are more likely to get pneumonia. People with chronic health problems are also at higher risk. Some of the most common signs and the pneumonia, severity of the patient's condition, and the patient's sta symptoms of pneumonia include coughing (mucus can be greenish yellow or occasionally bloody), fever. chest pain, and eral health will determine whether the patient needs to be admitted to severe chills. Most, but not all. patients complain of shortness of breath, either with or without exertion; chest pain that is tal. sharp and pleuritic (worsens on inhalation); headache; pale, sweaty skin; fatigue; and confusion, especially in the elderly.

Sometimes an older person will have only a few other signs or symptoms besides confusion. When you auscultate the chest, you may hear crackles on one side in just one region.

Immunization with a vaccine that prevents the most common types Prehospital care consists of supportive treatment that you would administer to any patient with difficulty breathing, If the pneumonia is thought to be bacterial, the patient will receive antibiotics at the emergency department, The cause of the pneumonia is an important and effective part of prevention for the pneumonia, severity of the patient’s condition, and the patient’s state of general health will determine whether the patient those with chronic health conditions. needs to be admitted to the hospital or not.

Immunization with a vaccine that prevents the most common types of bacterial pneumonia is an important and effective part of prevention for the elderly and those with chronic health conditions.

o e

SPONTANEOUS PNEUMOTHORAX

SPONTANEOUS PNEUMOTHORAX

When a lung collapses without injury or any other obvious cause, it is called a spontaneous pneumothorax. This is usually the result of rupture of a bleb, a small section of the lung that is weak. Once the bleb ruptures, the lung collapses and air leaks into the thorax. Certain conditions and activities place patients at higher risk of a spontaneous pneumothorax. Tall, thin people, for example, are more likely to have a weak spot that can rupture with just a cough. Smoking destroys lung tissue, so smokers are also at higher risk of this condition.

The patient with a collapsed lung typically has sharp, pleuritic chest pain and shortness of breath, although these may be mild when the pneumothorax is small.

When the area involved is larger, the patient will often tire easily, be tachycardic. breathe fast, have a low oxygen saturation, and exhibit cyanosis.

In the patient with a classic spontaneous pneumothorax, auscultation will reveal breath sounds that are decreased or absent on the side with the injured lung. This test is in patients with a suspected pneumothorax. not reliable, however, as some patients with Most patients with a pneumothorax will need When a lung collapses without injury or any other obvious cause, it a pneumothorax may have perfectly normal to have a small catheter or a larger plastic breath sounds. chest tube inserted between the ribs, then spontaneous pneumothorax.

This is usually the result of rupture of a bl Administer oxygen and treat the patient into the pleural space around the collapsed section of the lung that is weak. Once the bleb ruptures, (he lung coll like anyone else who is short of breath. As lung. The catheter will help remove the air. mentioned earlier, CPAP is contra-indicated air leaks into theallowing the lung to re-expand. thorax. Certain conditions and activities place patients

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risk of a spontaneous pneumothorax. Tall, thin people for example, likely !o have a weak spot that can rupture with just a cough.. Smokin lung tissue, so smokers are also at higher risk of this condition.

The patient with a collapsed lung typically has sharp, pleuritic chest shortness of breath, although these may be mild when the pneum

CTICE UNIT 3 DAY 12

PULMONARY EMBOLISM

PRINCIPLES OF EMT CLINICAL PRACTICE EPIGLOTTITIS

minister to e bacterial, Blood usually travels through the vessels in the lung, eventually getting to the capillaries, e cause of where oxygen and carbon dioxide are exchanged.

When something that is not blood—like a blood ale of genclot, air, or fat—tries to go through these blood o the hospivessels, it gets stuck and blocks an artery in the

EPIGLOTTITIS

lungs. This is a dangerous condition known as a pulmonary embolism.

The most common example of a pulmonary of bacterial embolism is a blood clot that starts in a vein, often a vein in the leg or in the pelvis. This elderly and dangerous type of clot is called a deep vein thrombosis (DVT). DVT can occur in a variety of situations. The three factors that increase the risk of DVT are limb immobility, local trauma to an extremity, and/or abnormally fast blood clotting.

Patients at increased risk for developing a DVT include women on birth control pills, patients with cancer, patients with lower extremity When an infection inflames the area around and above the an infection inflames the area around and above the epiglottis, the tissue injuries (such as casted fractures), and anyone When epiglottis, the tissue swells. If it swells enough, it can actually occlude, swells. If it swells enough, it can actually occlude, or close off, the airway. Epiglotwho is in the same position for a long period of titis used to beor close off, the airway. Epiglottitis is a disease that is more common in a disease of children, but it is now much less common in children in the United States. This is primarily the result of childhood vaccitime (such as transcontinental air travellers). than in adultschildren. But in recent years, it has also afflicted adult Filipinos, mostly against Haemophilus influenzae type B, the bacterium that used to cause Other things can block the pulmonary nation most cases ofmale. epiglottitis in children. arteries, though not as often as a blood clot. A The typical adult with epiglottitis is a male in his forties who The typical adult with epiglottitis is a male in his forties who may have had a resignificant amount of air introduced into a vein “ may have had a recent cold. Symptoms include sore throat and cent cold. Symptoms include sore throat and painful or difficult swallowing. The can cause great harm and even death. If fat gets patient is typically painful or difficult swallowing. The patient is typically in the tripod in the tripod position lo increase the glottic opening. Other a sick appearance, muffled voice, fever, and drooling because into the circulation—for example, from the signs may include position lo increase the glottic opening. Other signs may include a sick the pain and difficulty in swallowing. An alarming sign is stridor. This indicates marrow of a fractured bone—the same results of appearance, muffled voice, fever, and drooling because of the pain and the airway already has a significant degree of obstruction. can occur. difficulty in swallowing. An alarming sign is stridor. This indicates the the slower onset of symptoms in adults, children who have this The signs and symptoms of a pulmonary In contrast toairway already has a significant degree of obstruction. often experience a sudden onset. Although children between 2 and 7 embolus are extremely variable, making this disease In contrast to the slower onset of symptoms in adults, children years of age used to be the most likely lo experience epiglottitis it can now apone of the most difficult conditions to detect pear in a childwho have this disease often experience a sudden onset. Although of any age. The presentation of a still child leaning forward in the drooling, and appearing to be in distress should alert the EMT to The typical patient has sudden onset of sharp, tripod position, children between 2 and 7 years of age used to be the most likely lo the possibility of this disease, pleuritic chest pain: shortness of breath; anxiety; experience epiglottitis it can now appear in a child of any age. The a cough (sometimes with bloody sputum); sweaty Treatment forpresentation of a still child leaning forward in the tripod position, epiglottitis includes doing as much as possible to make the patient This means you should NOT inspect the throat. Administer skin that is either pale or cyanotic; tachycardia; calm and comfortable. drooling, and appearing to be in distress should alert the EMT to the high concentration oxygen if you can do it without alarming the patient. Transand tachypnea. Unfortunately, few patients port as soon as possibility of this disease. possible lo an emergency department capable of dealing with Be sure lo advise the start when you expect to arrive so that with a pulmonary embolism present in this this type of patient.Treatment for epiglottitis includes doing as much as possible to proper personnel can be there. Because of the possibility of sudden closure of way. The patient may also complain of feeling the make the patient calm and comfortable. This means you should NOT the airway, use of light and siren is justified for a patient like this unless you are lightheaded or dizzy, with pain and swelling in very close to the inspect the throat. Administer high concentration oxygen if you can hospital. If untreated, up to 10 percent of children with this disAdults can tolerate the swelling better but still bear the risk of losone or both legs. Wheezing is sometimes heard ease may die.do it without alarming the patient. Transport as soon as possible lo an on auscultation of the chest. If the clot is large, ing the airway. emergency department capable of dealing with this type of patient. Be the patient may be hypotensive or go into cardiac Limmer (Brady) sure lo advise the start when you expect to arrive so that the proper ³ Pollack, (AAOS) arrest. ⁴ NHTSA personnel can be there. Because of the possibility of sudden closure Administer oxygen and treat the patient like of the airway, use of light and siren is justified for a patient like this anyone else who is short of breath. Keep a high unless you are very close to the hospital. If untreated, up to 10 percent index of suspicion for pulmonary embolism in of children with this disease may die. Adults can tolerate the swelling patients with recent immobilizations or those better but still bear the risk of losing the airway. is called with a previous history of DVT. Pulmonary a Childhood epiglottitis can be prevented by administration of the embolus can sometimes be prevented by avoiding leb, a small Haemophilus influenzae type B vaccine. Adult epiglottitis, can result long periods of inactivity, refraining from from infection by many different microbes, so there is no known way lapses and smoking, taking appropriate medication when to prevent it in adults. s al higher there is a high risk of forming clots, and getting early care for DVT. , are more ²

ng destroys

t pain and mothorax is

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307

ildhood epiglottitis can be prevented by administration of the Haemophilus uenzae type B vaccine. Adult epiglottitis, can result from infection by many ferent microbes, so there is no known way to prevent it in adults.

YSTIC FIBROSIS

Day 12

RESPIRATION AND ARTIFICIAL VENTILATION

VIRAL RESPIRATORY INFECTIONS

One of the most common afflictions a person may get is a viral respiratory infection. There are many presentations, but it often starts with a sore or scratchy throat with sneezing, a runny nose, and a feeling of fatigue. There maybe a fever and chills. The infection can spread into the lungs,causing shortness of breath, especially in those who have chronic health conditions. The cough can be persistent and may produce sputum that is yellow or greenish.

Symptoms usually persist for 1 to 2 weeks.

Because the signs and symptoms of a respiratory infection resemble those of so many other diseases, the EMT should administer oxygen and care for the patient like any other patient with respiratory distress.

Because the infection is viral, antibiotics do not help and may worsen things by promoting antibiotic resistance.

This happens when a patient receives an unnecessary antibiotic, resulting in killing off bacteria except for the ones that are resis-tant to that antibiotic.

Good hygiene can help prevent viral respiratory genetic disease that typically appears in childhood, cystic fibrosis (CF) causes infections, Before touching your hand to your nose or eyes. ck, sticky mucus that accumulates in the lungs and digestive system. Thebe sure it is clean. If you have shaken hands with someone muA genetic disease that typically appears in childhood, who is carrying the virus, it can he transmitted lo you and s can cause life threatening lung infections and serious problems with digescystic fibrosis (CF) causes thick, sticky mucus that then introduced into your system through the mucous n. Signs and symptoms may include: accumulates in the lungs and digestive system. The mucus membranes of the nose and eyes. Alcohol-based hand  Coughing with large amounts of mucus from the lungs can cause life threatening lung infections and serious sanitizer can be very helpful. Avoiding the spray of a sick  Fatigueproblems with digestion. Signs and symptoms may include: person who is sneezing or coughing will also reduce your Coughing with large amounts of mucus from the lungs  Frequent • occurrences of pneumonia, characterized by fever, more risk of contracting a viral respiratory infection.

Fatigue coughing• than usual, worse shortness of breath than usual, more spuFrequent occurrences of pneumonia, characterized by tum than • usual, and loss of appetite fever, more coughing than usual, worse shortness of  Abdominal breath than usual, more sputum than usual, and loss of pain and distention  Coughing up blood appetite  Nausea • Abdominal pain and distention A patient with asthma, COPD, or similar chronic • Coughing up blood illness may have an inhaler prescribed by a physician. You  Weight loss • Nausea will need to get permission from medical direction to help Weight loss ou encounter a• patient with CF. the patient or parent will be able to tellthe patient use the inhaler. This may be accomplished by you phone/radio or by standing order, depending on your local out how the disease affects the child.

Although most patients with this disease If you encounter a patient with CF. the patient or parent protocols. Keep in mind that a patient may overuse the e children, many of these patients are now surviving lo adulthood, something will be able to tell you about how the disease affects the inhaler prior to your arrival, so it is important to determine at was almostchild. Although most patients with this disease are children, unheard of a generation ago. The patient or parent will be very exactly when and how many times the inhaler has been miliar with themany of these patients are now surviving to adulthood, disease and what usually works for the patient. Use their knowlused. Be sure to give this information to medical direction. ge to your advantage. something that was almost unheard of a generation ago. The The metered-dose inhaler gets its name from the fact patient or parent will be very familiar with the disease and that each activation of the inhaler provides a metered, or ere is no known way to prevent cystic fibrosis, although a great deal of rewhat usually works for the patient. Use their knowledge to exactly measured, dose of medication. Most patients simply arch is going your advantage. on in this area. refer to the device as their “inhaler” or “puffer.” The inhaler There is no known way to prevent cystic fibrosis, is prescribed for patients with respiratory problems that although a great deal of research is going on in this area. cause broncho constriction (constriction, or blockage, of the bronchi that lead from the trachea to the lungs) or other types of lung obstructions. The inhalers contain a drug that dilates, or enlarges, the air passages, making breathing easier. These drugs are in the form of a fine powder. The timing of the activation of the inhaler in relation to a deep breath is very important to prevent the fine powder from

CYSTIC FIBROSIS

THE PRESCRIBED INHALER

Limmer (Brady) Pollack, (AAOS) NHTSA

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coming to rest on the innermost surface of the mouth. The medication will work only if it comes in contact with lung tissue directly. Studies have shown that inhalers can be very beneficial—but only when used properly.

Spacer devices make the exact timing necessary to use an inhaler less critical. The inhaler is activated into the spacer device (sometimes called an aerochamber. The medication stays airborne inside the chamber and can then be inhaled directly into the lungs.

When patients use an inhaler, they often are excited or nervous because they are short of breath. Many do not use their inhaler properly. Some people have never had proper instruction in the use of their inhaler.

Make sure to calm the patient the best you can and coach him to use the inhaler properly, as follows: 1. As with any medication, ensure that you have the right patient, the right time, the right medication, the right dose, and the right route. Check the expiration date. Make sure the inhaler is at room temperature or warmer. Shake the inhaler vigorously several times.

2. Make sure that the patient is alert enough to use the inhaler properly. Use a spacer device if the patient has one available.

3. Make sure the patient first exhales deeply.

4. Have the patient put his lips around the opening and press the inhaler to activate the spray as he inhales deeply.

5. After the patient inhales, make sure he holds his breath as long as possible so the medication can be absorbed. This may be difficult with a patient who is anxious but unless the medication is held in the lungs, it will have minimal or no value.

CRITICAL DECISION MAKING Assisting with a Prescribed inhaler As an EMT. you may he allowed to assist a patient in using his prescribed inhaler. Certain inhalers deliver a medication that relaxes narrowed airways and provides tremendous benefit to the patient when they arc used properly.

NOTE: There are many types of drugs used in prescribed inhalers. The so-called “rescue inhalers” act immediately in an emergency to reverse airway constriction. Fastacting emergency inhalers include inhalers that contain albuterol (Ventolin, Proventil, Volmax), levalbuterol (Xopenex), and combination inhalers containing albuterol and ipratropium (Combivent and DuoNeb). Other inhalers are not for use in emergencies: rather, they are used daily to help reduce inflammation and prevent attacks.

These medications (e.g..

Beclomethasone, Flovent, Advair) should not be used to reverse an acute attack, nor should they be used in the event of breathing difficulty or airway constriction. Fast acting emergency inhalers include albuterol inhalers (Ventolin, Preventil) and combination inhalers (Combivent).

Your role will involve more coaching than actually administering the medication. Follow local protocols and consult medical direction, if required, before assisting a patient with an inhaler.

PRESCRIBED INHALER Medication Name

1. Onerk; albuterol, isoetharine, metaproterenol 2. Trade: Proventil, Ventolin, Bronkosol, Bronkometer, Alupent, Metaprel

Indication

Meets all the following criteria:

1. Patient exhibits signs and symptoms of respiratory emergency.

2. Patient has physician prescribed handheld inhaler.

3. Medical direction gives specific authorization to use.

Contraindication

1. Patient is unable to use the device (e.g., not alert).

2. Inhaler is not prescribed for the patient.

3. No permission has been given by medical direction 4. The patient has already taken the maximum prescribed dose prior to the EMT’s arrival.

Medication Form —Handheld

metered-dose inhaler.

Dosage

—Number of inhalations based on medical direction’s order or physician’s order.

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Day 12

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CRITICAL CONCEPTS • Respiratory emergencies are common complaints for EMTs. It is important to understand the anatomy, physiology, patho-physiology, assessment, and care for patients experiencing these emergencies.

• Patients with respiratory complaints (which are closely related to cardiac complaints) may exhibit inadequate breathing. Rapid respirations indicate serious conditions including hypoxia, cardiac and respiratory problems, and shock.

• Very slow and shallow respirations are often the endpoint of a serious condition and are a precursor to death.

• The history usually provides significant information about the patient’s condition. In addition to determining a pertinent past history and medications, determine the patient’s signs and symptoms with a detailed description including OPORST and events leading up to the episode.

• Important physical examination points include checking the patient’s work of breathing, inspecting accessory muscle use, gathering pulse oximetry readings, assuring adequate and equal lung sounds bilaterally, examining for excess fluid (lungs, ankles, and abdomen), and gathering vital signs.

• Several medications are available that may help correct a patient’s difficulty in breathing.

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Ganito ang paraan na dapat sundin sa pagbibigay-lunas sa isang pasyente gamit ang inhaler: 1. Humingi muna ng pahintulot sa medical director para gumamit ng inhaler.

2. Seguruhin na tama ang pasyente, tama ang panahon, tama ang gamot, tama ang dosage, at tama ang paraan ng pagbibigay lunas. Tiyakin din na may malay at malinaw ang isip ng pasyente na gagamit ng inhaler.

3. Suriin ang expiration date ng inhaler.

Kung expired na, huwag na itong gamitin.

4. Itanong sa pasyente kung kelan siya huling gumamit ng inhaler. Huwag magoverdose.

5. Tiyakin na nasa room temperature ang inhaler.

6. Alugin muna nang mabuti ang inhaler bago gamitin.

7. Sabihan ang pasyente na huminga na ilagay sa labi ang inhaler at huminga nang malalim kapag napisil na niya ito.

8. Sabihan ang pasyente na huwag muna ibuga ang hangin pagkahigop sa inhaler para matiyak na papasok sa baga ang gamot.

Actions

—Betaagonist bronchodilator dilates bronchioles, reducing airway resistance.

Side Effects 1. Increased pulse rate 2. Tremors 3. Nervousness

Reassessment Strategies 1. Gather vital signs.

2. Perform a focused reassessment of the chest and respiratory function. Observe for deterioration of the patient; if breathing becomes inade-quate, provide artificial respirations.

THE SMALL-VOLUME NEBULIZER The medications used in metered-dose inhalers can also he administered by a small-volume nebulizer (SVN). Nebulizing a medication involves running oxygen or air through a liquid medication. The patient breathes the vapors created. Small-volume nebulizers are used in hospitals and ambulances; they are also prescribed to patients.

Patients with chronic respiratory conditions such as asthma, emphysema, or chronic bronchitis may have these devices in their homes. Unlike the inhaler, which is used in only one breath. a nebulizer produces a continuous flow of aerosolized medication that can be taken in during multiple breaths over several minutes giving the patient a greater exposure lo the medication.

The side effects and precautions with nebulized medications are the same as noted for prescribed inhalers. Patients may experience an increased pulse rate, tremors, nervousness, or a “jittery” feeling. Patients who are not breathing adequately will not benefit from a nebulizer, since they are not breathing deeply enough get the medication into their lungs.

Small-Volume Nebulizer (SVN)— Patient Assessment and Management 1. Identify the patient as a candidate for nebulized medication per protocol (e.g., history of asthma with respiratory distress). Administer oxygen and assess vital signs. Be sure the patient is not allergic to the medication.

2. Obtain permission from medical direction to administer or assist with the medication, 3. Ensure the five rights (right patient, right time, right medication, right dose, right route). Prepare the nebulizer. Put the liquid medication in the chamber. Attach the oxygen tubing and set the oxygen flow for 6 to 8 liters per minute (or according to manufacturer’s recommendations).

4. Have the patient seal his lips around the mouthpiece and breathe deeply. Instruct the patient to hold his breath for 2 to 3 seconds if possible. Continue until the medication is gone from the chamber, 5. Use an alternative device—a mask delivers the medication.

6. Reassess the patient’s level of distress and vital signs. Additional doses may be authored by medical direction if the patient continues to be in distress and the patient is not having adverse effects from the medication.

RESPIRATORY COMPENSATION 1. Compensation for hypoxia or hypercapnea is predictable 2. Signs: a. Shortness of breath (symptom) b. Increased respiratory rate and depth c. Increased heart rate 3. Respiratory Distress – body compensating for a respiratory challenge and meeting metabolic needs a. Signs of Respiratory Distress i. Relatively normal mental status ii. Relatively normal oxygen saturation and end tidal carbon dioxide iii. Relatively normal skin color iv. Shortness of breath v. Increased respiratory rate and heart rate vi. Accessory muscle use and position changes 4. Respiratory Failure a.k.a Inadequate Breathing– occurs when challenge overcomes compensation or compensatory steps can no longer continue; often a precursor to respiratory arrest. a. Signs of Respiratory Failure i. Signs of Respiratory distress ii. Evidence that compensation is no longer effective iii. Signs of poor oxygenation and/or poor removal of CO2 1) Altered Mental Status – occurs as hypoxia and hyper-capnea set in 2) Cyanosis – indicates profound hypoxia iv. Signs of decompensation 1) No or poor air movement 2) Diminished or absent breath sounds 3) Breathing rate too rapid, too slow, or irregular 4) Patient unable to speak 5) Unusual noises (wheezing, crowing, stridor, snoring, gurgling, gasping)

CRITICAL CONCEPTS 1. Tidal Volume - amount of air moved in one breath 2. Dead Air Space – air moved in ventilation not reaching alveoli 3. Alveolar ventilation – amount of air that actually reaches the alveoli 4. Diffusion – movement of gases from high concentration to low concentration 5. External Respiration – diffusion of oxygen and carbon dioxide (exchange of gases) between alve-oli and circulating blood.

6. Internal Respiration – exchange of gases between blood and cells

Pediatric Note: In addition to other signs, look for a) Retractions b) Nasal flaring c) Grunting d) Seesaw breathing

Kapag hindi makahinga ang pasyente, nagkakaroon ito ng respiratory compensation.

Lumalalim ang hugot ng hininga, bumibilis ang tibok ng puso, at kinakapos sa hangin. Kapag tumindi ang problema, respiratory distress at respiratory failure na ang nagiging kondisyon ng pasyente. Alamin ang mga senyales na magsasabi sa iyo ng kondisyon ng pasyente at gawin mo ang mga nararapat mong gawin para matulungan ito.

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ii. 20 per minute in Children iii. Minimum of 20 per minute in Infants . Increasing pulse rates – indicate inadequate artificial ventilation in Adults Decreasing Pulse Rates – indicate inadequate artificial ventilation in pediatRESPIRATION AND ARTIFICIAL VENTILATION Day 12 ric patients

Methods / Techniques of Artificial ventilation

POSITIVE PRESSURE entilatingVENTILATION (PPV) a Breathing Patient UNIT 3

1. Goal –Positive Pressure Ventilation (PPV) is also called to increase tidal volume PRINCIPLES OF EMT CLINICAL PRACTICE DAY 12 a. Mouth to Mask ventilation artificial ventilation . It is Forcing air or oxygen into 2. Explain procedure to patient lungs when a patient has stopped breathing or has i. Performed using a pocket face mask – made of soft, inadequate breathing . Uses force exactly opposite of how 3. After sealing mask on patient’s face, squeeze bag with patient’s inhalacollapsible material and can be carried in your jacket, the body normally draws air into lungs . Under normal pocket, or purse. circumstances, the respiratory system would create a Key Concerns tion with PPV ii. Have one-way valve that allow ventilations to enter negative pressure within the chest cavity to pull in air. With but prevent the patient’s exhaled air from coming back a. Do not ventilate patient who is vomiting or has vomitus in airway – PPV artificial ventilation, positive pressure is used to push air in. will force vomitus into patient’s lungs through the valve. b. Watch chest rise and fall with each ventilation iii. Connect oxygen and run at 15 lpm c. Ensure rate of ventilation is sufficient iv. Position mask on Patient’s face d. Ventilation Rates per 1) Apex over bridge of nose i. 10 – 12 minute in Adults minute 2) Base between lower lip and prominence of chin ii. 20 per in Children a. Decreasing cardiac output/dropping blood pressure iii. Minimum of 20 per minute in Infants 3) Hold mask firmly in place; maintain head tilt

i. Negative pressure ventilation assists the filling of e. Increasing pulse rates – indicate inadequate artificial ventilation in Adults 4) Exhale into mask port f. Decreasing Pulse Rates – indicate inadequate artificial ventilation in pediat the heart.

5) Allow passive exhalation

ii. Positive pressure defeats this filling assistance ric patientsv. Achieving tight Mask Seal—position thumbs over b. Gastric distention – filling of the stomach with air Ventilating atop if mask, Index fingers over bottom of mask and Breathing Patient that occurs when air is pushed through the esophagus remaining fingers under patient’s jaw 1.

Goal – to increase tidal volume during PPV 2. Explain procedure to patient

i. Side Effects: 3. After sealing mask on patient’s face, squeeze bag with patient’s inhala 1) Vomiting tion

2) Restriction of the diaphragm c. Hyperventilation – causes too much CO2 to be blown off. This causes vaso-constriction in the body and can Methods / Techniques of Artificial ventilation limit blood flow to the brain

ethods /Negative Techniques of Artificial ventilation Side Effects: Mouth to Mask ventilation

i. performed using a pocket face mask – made of soft, collapsible material and can be carried in your jacket, pocket, or purse. a. Mouth to Mask ventilation ii. Have one-way valve that allow ventiKey Concerns with PPV lations to enter but prevent the pa-i. performed using a pocket face mask – a. Do not ventilate patient who is vomiting or has of soft, collapsible material and tient’s vomitus in airway – PPV will force vomitus into exhaled air from coming back made can be carried in your jacket, pocket, or purse. patient’s lungs through the valve. ii. Have one-way valve that allow ventib. Watch chest rise and fall with each ventilation to enter but prevent the pac. Ensure rate of ventilation is sufficient iii. Connect oxygen and run at 15 lpm lations tient’s exhaled air from coming back d. Ventilation Rates through the valve. iv Position mask on“ Patient’s face

i. 10 – 12 per minute in Adults iii. Connect oxygen and run at 15 lpm iv Position mask on Patient’s face ii. 20 per minute in Children 1) Apex over bridge of nose 1) Apex over bridge of nose iii. Minimum of 20 per minute in Infants Base between lower lip and 2)e. Increasing pulse rates – indicate inadequate artificial Base between lower lip and 2) prominence of chin ventilation in Adults 3) Hold mask firmly in place; mainprominence of chin f. Decreasing Pulse Rates – indicate inadequate artificial tain head tilt into mask port ventilation in pediatric patients 3) Hold mask firmly in place; main- 4)5) Exhale Allow passive exhalation V.. Achieving tight Mask Seal—position tain head tilt thumbs over top if mask, Index fingers Ventilating a Breathing Patient 4) Exhale into mask port over bottom of mask and remaining 1. Goal – to increase tidal volume fingers under patient’s jaw Explain procedure to patient 5)2. Allow passive exhalation 3. After sealing mask on patient’s face, squeeze bag with patient’s inhalation V.. Achieving tight Mask Seal—position thumbs over top if mask, Index fingers over bottom of mask and remaining 312 LIFELINE PREHOSPITAL EMERGENCY CARE fingers under patient’s jaw ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

valve, face mask, oxygen reservoir. ii. Used to ventilate nonbreathing patient and/or patient in respiratory failure. iii. Standard Feature of BVM 1) Self-refilling that is easily cleaned and sterilized 2) Non-jam valve that allows an oxygen inlet flow f 15 Lpm 3) Nonrebreathing Valve 4) should perform in all environmental conditions and temperature extremes 5) Available in infant, child, and adult sizes.

Iv. Mechanics of BVM 1) Supply of 15 lpm O2 attached and enters reservoir 2) when squeezed, air inlet closed and oxygen delivered to patient 3) When released, passive expiration by patient occurs.

b. Bag-Valve Mask (BVM)

i. Handheld ventilation device – consists of a self- inflating bag, one-way valve, face mask, oxygen reservoir. ii. Used to ventilate nonbreathing patient and/or patient in respiratory failure. iii. Standard Feature of BVM:

1) Self-refilling that is easily cleaned and sterilized

2) Non-jam valve that allows an oxygen inlet flow of

15 Lpm.

3) Nonrebreathing Valve.

4) should perform in all environmental conditions

and temperature extremes.

5) Available in infant, child, and adult sizes. “ Iv. Mechanics of BVM:

1) Supply of 15 lpm O2 attached and enters

reservoir.

2) when squeezed, air inlet closed and oxygen

delivered to patient.

3) When released, passive expiration by patient

occurs. v. Two-Rescuer BVM Ventilation

1) Strongly recommended by AHA

2) Most difficult of BVM ventilation is obtaining

adequate mask seal.

3) Hard to maintain seal while squeezing bag.

4) One rescuer squeezes bag; other rescuer

maintains seal.

5) No trauma Suspected

a) Open airway with head-tilt m chin-lift

maneuver.

b) Select correct bag-valve mask size.

c) Kneel at patient’s head; position thumbs over

top half of mask, index finger over bottom

half.

d) Place apex of triangular mask over bridge of

nose; lower mask over mouth and upper

chin.

e) Use middle, ring, and little fingers to bring

patient’s jaw up to mask.

f) Maintain head-tilt, chin-lift maneuver .

g) Second rescuer connects and squeezes bag.

h) Second rescuer releases bag; patient exhales

passively.

6) Trauma Suspected

a) Open airway using jaw-thrust maneuver.

b) Select correct bag-valve mask size.

c) Kneel at patient’s head; place thumb sides of

your hands along mask to hold it firmly

on patient’s face.

d) Use remaining fingers to bring jaw upward

toward mask, without tilting head or neck.

v. Two-Rescuer BVM Ventilation 1) Strongly recommended by AHA vi.

One-Rescuer BVM Ventilation 2) difficult of BVM ventilation is obtaining adequate mask seal Most1) Provide ventilations with a one-rescuer BVM Hard to maintain seal while squeezing bag 3)

procedure only when no other options are 4) One rescuer squeezes bag; other rescuer maintains seal 5) No trauma available.

Suspected a) 2) Procedure Open airway with head-tilt m chin-lift maneuver b) Select a) Open airway. correct bag-valve mask size at patient’s head; position thumbs over top half of mask, c) Kneel b) Select correct size of mask. finger over bottom half

index c) Position mask in patient’s face. d) place apex of triangular mask over bridge of nose; lower mask

over d) Squeeze bag. mouth and upper chin

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

e) Release pressure on bag and let patient

exhale passively.

viii. Bag to stoma or tracheostomy tube

1) Stoma – a surgical opening in the neck through

which tha patient breathes.

2) Procedure

a) Clear mucus plugs or secretions from stoma.

b) Leave head and neck in nuetral position.

c) Use pediatric-sized mask to establish seal

around stoma.

d) Ventilate at appropriate rate for patient’s age.

e) If unable to artificially ventilate through.

stoma, seal stoma and attempt artificial

ventilation through mouth and nose.

NOTE:

If Chest Does Not Rise During BVM Ventilation 1) Reposition head 2) Check for escape of air around mask; reposition fingers and mask 3) Check for airway obstruction or obstruction in BVM system 4) Use alternative method

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5) Should deliver no mo to 6 lpm

Non-Rebreather Ma Day 12

1) best way to deliver Ma hig RESPIRATION AND ARTIFICIAL VENTILATION Non-Rebreather

DELIVERY DEVICES

c. Flow restricted, oxygen powered UNIT 3 OF EMT CLINICAL PRACTICE ventilation – DAY device 12 PRINCIPLES Also called a manally triggered ventilation device.

i. Recommended Features: DELIVERY DEVICES

1) Peak flow rate of 100% ixygen at up to 40 liters per minute.

Nasal Cannula

2) Inspiratory pressure relief valve that opens at approximately 60 cm of water pressure.

1) best choice for patient who re 3) Auduble alarm when the lift valve is activated fuses to wear an oxygen face

4) Trigger that enables the rescuer to use both hands mask to maintain a mask seal while triggering the 2) oxygen is delivered by two device. prongs that rest in the patient’s ii. Use on adult only. nostrils iii. Follow same procedures for mask seal as for BVM 3) usually held to the patient’s face iv. Trigger device unti chest rises. by placing the tubing over the

1) If the chest does not rise patient’s ears and securing the

a) Reposition the head. slip-loop under the patient’s

b) Check the mask seal. chin

c) Check for obstructions.

4) Provides oxygen concentrations

d) Consider the use of an alternative artificial of 24% to 44%

ventilation procedure.

5) Should deliver no more than 4 to 6 lpm

“

trations of oxygen to ing patient 1) best way to deliver hig 2) Provides oxygen conc trations of oxygen to of 80% to 100% ing patient 3) flow rateconc 8 lp 2) Minimum Provides oxygen 4) Maximum flow rate 12 of 80% to 100% 3) Minimum flow rate 8 lp 4) Maximum flow rate 12

Nasal“ Cannula

Partial Rebreather M

1) Very Rebreather Similar to nonM Partial

UNIT 3 DAY 12

mask 2) one-way in o 1) No Very Similarvalve to non reservoir bag mask 3) 40% valve to 60% 2) Delivers No one-way in oo to 10 lpm reservoir bag

PRINCIPLES OF E

3) Delivers 40% to 60% o

1) Best choice for patient who re-fuses to wear an to 10 lpm oxygen face mask.

2) Oxygen is delivered by two prongs that rest in Venturi Mask the patient’s nostrils.

Non-Rebreather Mask 3) Usually held to the patient’s face by placing the 1) delivers specific concentr ² Limmer (Brady) i. Provides Automated ventilations. tubing over the patient’s ears and securing the ³ Pollack, (AAOS) 1) best way to deliver high concen⁴ NHTSAby mixing oxygen ii. Can Adjust ventilation rate and volume. oxygen slip-loop under the patient’s chin. trations of oxygen to a breathiii. Provider must assure appropriate respiratory rate 4) Provides oxygen concentrations of 24% to 44%. haled air (Brady) ² Limmer ing patient and volume fro patient’s size and condition. ³ Pollack, (AAOS) 2) Provides oxygen concentrations 5) Should deliver no more than 4 to 6 lpm.

2) some⁴ NHTSA have set percentage of 80% to 100% rate; others have adjustab 3) Minimum flow rate 8 lpm port 4) Maximum flow rate 12 to 15 lpm 3) May contain several tips – will provide different conc “ of oxygen when used at rate designated on the tip.

1. Conditions requiring Supplemental Oxygen b. Oxygen Cylinders a. Respiratory or Cardiac Arrest i. Sizes b. Heart Attacks and Strokes 1) D – about 350 L of O2 c. Shock 2) E – about 625 L of O2 d. Respiratory Distress and Lung Diseases 3) M – about 3, 000 L of O2 e. Head Injuries Partial Rebreather Mask 4) G – about 5, 300 L of O2 f. Other serious Injuries 5) H – about 6, 900 L of O2 2. Oxygen System / Oxygen Delivery System

c. Pressure Regulators 1) Very Similar to nonrebreather a. Contains: i. decreases pressure to provide a safe working level mask Tracheostomy Mask i. Oxygen cylinder toii. On Cylinders of E or smaller – pressure regulator is 2) No one-way valve in opening ii. Pressure regulators reservoir bag

secured using specific pins that mustt mate with iii. Delivery device 3) Delivers 40% to 60% oxygen

9 corresponding holes in the valve assembly. at 1) Placed over stoma or Tra to 10 lpm tube to provide supplement 2) Connected to 8 to 10 lpm

D. Automated Transport Ventilator (ATV)

Supplemental Oxygen Therapy

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² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

rate; others have adjustable venturi port 3) May contain several tips – wach tip will provide different concentration of oxygen when used at the flow rate designated on the tip.

ore than 4

ask

Non-Rebreather Mask

gh askconceno a breath-

Tracheostomy Mask 1) Best way to deliver high concentrations of oxygen to a breathing patient.

1) Placed over stoma or Tracheostomy 2) Provides oxygen concentrations of tube to provide supplemental oxygen 80% to 100%.

2) Connected to 8 to 10 lpm 3) Minimum flow rate 8 lpm.

4) Maximum flow rate 12 to 15 lpm.

Tracheostomy Mask

gh concenocentrations a breath-

pm centrations 2 to 15 lpm

pm 2 to 15 lpm

1) Placed over stoma or Tracheostomy tube to provide supplemental oxygen 2) Connected to 8 to 10 lpm

“

Mask

nrebreather Mask

opening to nrebreather

“

oxygen 9 openingatto EMT CLINICAL PRACTICE

oxygen at 9

Partial Rebreather Humidifier Mask 1) Connected to flowmeter 1) Very Similar to nonrebreather mask.

2) Provides moisture to dry oxygen 2) No one-way valve in opening from supply cylinder to reservoir bag.

Humidifier 3) Delivers 40% to 60% oxygen at 9 to 10 lpm.

Tracheostomy Mask 1) Placed over stoma or Tracheostomy tube to provide supplemental oxygen.

2) Connected to 8 to 10 lpm.

1) Connected to flowmeter 2) Provides moisture to dry oxygen from supply cylinder

Venturi Mask

rations of n with in-

1) Delivers specific concentrations of oxygen by mixing oxygen with inhaled air.

2) Some have set percentage and flow rate; others have adjustable venturi port.

3) May contain several tips – wach tip ² Limmer (Brady) ³will provide different concentration Pollack, (AAOS) ⁴ NHTSA of oxygen when used at the flow rate designated on the tip.

e and flow ble venturi

– wach tip centration t the flow .

Special Considerations

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

1. Facial Injuries Bleeding and swelling can disrupt. movement of air Aggressive suction and advanced airway maneuvers may be necessary.

2. Obstructions a. foreign bodies can impede ventilation of patients b. if unable to ventilate always consider the acheostomy possibility of obstruction. tal oxygen

Humidifier 1) Connected to flowmeter.

2) Provides moisture to dry oxygen from supply cylinder.

3. Pediatric Note a. Hypoxia often occurs rapidly

i. Children burn oxygen at twice the rate of adults.

ii. Account for many anatomical differences associated

with airway. b. Ventilating Pediatric Patient

i. Avoid excessive pressure and volume.

ii. Use properly sized face masks.

iii. Flow-restricted oxygen-powered ventilation devices

contraindicated.

iv. Gastric distention may impair adequate ventilations.

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cated iv. Gastric distention may impair adequate ventilations

BASIC AIRWAY ADJUNCTS Oropharyngeal Airways (OPA) Day 12

RESPIRATION AND ARTIFICIAL VENTILATION

UNIT 3 PRINCIPLES a. keep the tongue from blocking the upper DAY 12 airway b. allow for easier suctioning of airway

BASIC AIRWAY ADJUNCTS

OF EMT CLINICAL PRACTICE

c. used in conjuction with BVM device d. Used on unconscious patients without gag reflex

Oropharyngeal Airways (OPA)

Nasopharyngeal Airways

Inserting an Oropharyngeal Airway i. Select the proper size airway – from the corner of the patient’s lips to the bottom of the earlobe or angle of jaw ii. Open the patient’s mouth a. Keep the tongue from blocking the upper airway. a. Conscious patients who cannot maintain airway. a. the conscious patients who cannot maintain airway iii. Hold the airway upside down and insert it in patient’s b. A llow for easier suctioning of airway. b. Cmouth an be used with intact gag reflex. iv. Rotate the airway 180 degrees until the flange restsbe onused the patient’s b. can with intact gag reflex c. Used in conjuction with BVM device. c. Should not be used with head injuries or nosebleeds. lips. c. should not be used with head injuries or nosebleeds d. Used on unconscious patients without gag reflex. v. Another method – using a tongue depressor to press the tongue down and forward to avoid obstructing the airway (preferred method in an infant and child) Inserting a Nasopharyngeal airway

Nasopharyngeal Airways

Inserting an Oropharyngeal Airway

Inserting a Nasopharyngeal airway

i. Select the proper size airway – from i. Select the proper size airway the tip of the nose to the tip of the – from the tip of the nose to patient’sthe tip of the patient’s ear; also ear; also consider diameter of airway in the nostril consider diameter of airway in the nostril. ii. Lubricate the airway ii. Lubricate the airway. iii. gently push the nostrip open iv. Withiii. Gently push the nostrip open the bevel turned toward the iv. With the bevel turned septum, toward the septum, insert the airway

i. Select the proper size airway – from the corner of the patient’s lips to the bottom of the earlobe or angle of jaw. ii. Open the patient’s mouth. iii. Hold the airway insert the airway. upside down and ² Limmer (Brady) ³ Pollack, (AAOS) insert it in the patient’s mouth. ⁴ NHTSA iv. Rotate the airway 180 degrees until the flange rests Assisting with Advanced Airway Devices on the patient’s lips. v. Another method – using a tongue depressor 1. Two General Categories of Advanced Airway Devices to press the tongue down and forward to avoid a. Devices requiring direct visualization – glottic opening obstructing the airway (preferred method in an infant and child). b. Devices inserted “blindly” 2. Assiting with Intubation a. Maximize oxygenation prior to procedure i. Hyperoxygenation – accomplished by ventilating with BVM ““ and includes a reservoir. device that is connected to oxygen b. Position patient in sniffing position c. Cricoid Pressure – applied by pressing the thumb and index finger d. Confirmation is obtained by using: 1. Two General Categories of Advanced just to oeither side of the throat over the cricoid cartilage.

i. Auscultation of both lungs and the Airway Devices. “ d. is obtained by using: Confirmation

epigastrium. a. Devices requiring direct visualization – i. auscultation ii. Capnometry or an end-tidal CO of both lungs and the epigastrium

glottic opening.

detector device. b. Devices inserted “blindly”. ii. capnometry or an end-tidal CO detector device e. Securing tube in place.

2. Assiting with Intubation e. Securing tube in place f. Ventilating the Intubated Patient a. Maximize oxygenation prior to

f. Ventilating the Intubated Patient i. very i. Very little movement can displace an

procedure. little movement can displace an endotracheal tube

endotracheal tube.

i. Hyperoxygenation – accomplished ii. pay attention to resistance to ventilations; report changes

ii. Pay attention to resistance to

by ventilating with BVM device iii. if patient is defibrillated, carefully remove bag from tube

ventilations; report changes.

that is connected to oxygen 3. Assiting withiii. If patient is defibrillated, carefully a Trauma Intubation

and includes a reservoir.

remove bag from tube. a. provide manual in-line stabilization throughout procedure b. Position patient in sniffing position 3.

Assiting with a Trauma Intubation c. Cricoid Pressure – applied by pressing b. position hands to hold stabiliation, but allow for movement of a. Provide manual in-line stabilization

the thumb and index finger just to jaw

Assisting with Advanced Airway Devices

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either side of the throat over the cricoid cartilage.

PREHOSPITAL EMERGENCY CARE

² Limmer (Brady) ³ Pollack, (AAOS)

throughout procedure. b. Position hands to hold stabiliation, but allow for movement of jaw.

Patient Care

Breathing Difficulty 7.7.Assessment Assessment––Vital VitalSign SignChanges Changes

1. Patient’s subjective perception. e. Noisy breathing a.a.increased increasedor ordecreased decreasedpulse pulserate rate 2. Feeling of labored, or difficult,

i. Audible wheezing (heard b. b.changes changesin inbreathing breathingrate rate breathing.

without stethoscope).

3. Amount of distree felt may or may

ii. Gurgling. c.c.changes changesin inbreathing breathingrhythm rhythm not reflect actial severity of condtion. iii. Snoring. d. d.hypertension hypertensionor orhypotension hypotension 4. OPQRST mnemonic

iv. Crowing. e.e.oxygen oxygensaturation saturation a. Onset – When did it begin.

v. Stridor. b. Provocation – What were you 6. Assessment – Auscultation doing when this came on. a. Lung sounds on both sides during c. Quality – Do you have a cough? Are

inspiration and expiration.

Patient Patient Care Care you bringing anything up with it.

i. Wheezes – High- pitched 1.1.Assure Assureadequate adequateventilations ventilations d. Radiation – Do you have pain or

sounds created by air moving discomfort anywhere else in your

through narrowed air 2.

2.ififbreathing breathingisisinadequate, inadequate,begin beginartificial artificial ventilation ventilation body.

at passages.

3.

3.ififbreathing breathingisisadequate, adequate,non-rebreather non-rebreather mask mask at 15 15lpm lpm e. Severity – On a scale of 1 to 10,

ii. Crackles – Fine crackling 4.

4.place placepatient patientin inposition positionof ofcomfort comfort how bad is your breathing trouble.

caused by fluid in f. Time – How long have you had this

alveoli or by opening of 5.5.administer administerprescribe prescribeinhaler inhaler 6. f6. eeling.

administer administercontinuous continuouspositive positiveairway airwaypressure pressureclosed alveoli.

(CPAP) (CPAP) 5. Assessment – Observation

iii. Rhonchi – Low sounds a.a.simple simpleprinciples principles a. Altered mental status.

resembling snoring b. Unusual anatomy – barrel chest.

at or rattling, caused by i.i. blowing blowing oxygen oxygen or or air air continously continously at low low pressure pressure into into airairc. Patient’s position

secretions in larger

way way

i. Tripod position.

airways. ii.ii.prevents preventsalveoli alveolifrom fromcollapsing collapsing at atend endof ofexhalation exhalation

ii. Sitting with feet dangling,

iv. Stridor – High –

leaning forward.

alveoli pitched, upper-airway iii. iii. can can prevent prevent fluid fluid shifting shifting into into alveoli from from surrounding surrounding d. Work of breathing

sounds indicating partial capillaries capillaries

i. Retractions.

obstruction of

b. b.common commonuses uses

ii. Use of accessory muscles.

trachea or larynx.

iii. Flared nostrils.

7. Assessment – Vital Sign Changes i.i.pulmonary pulmonaryedema edema

iv. Pursed lips. a. Increased or decreased pulse rate. ii.ii.drowning drowning

v. Number of words patient b. Changes in breathing rate. iii.asthma asthmaand andCOPD COPD

can siii. ay without stopping. c. Changes in breathing rhythm.

vi. Pale, cyanotic, or flushed d.Hypertension or hypotension. iv. iv.respiratory respiratoryfailure failurein ingeneral general

skin. e. Oxygen saturation.

vii. Pedal edema.

viii. Sacral edema.

ix. Coughing.

1. Assure adequate ventilations.

2. If breathing is inadequate, begin artificial ventilation.

3. If breathing is adequate, nonrebreather mask at 15 lpm.

4. Place patient in position of comfort.

5. Administer prescribe inhaler.

6. Administer continuous positive airway pressure (CPAP). a. Simple principles. i. Blowing oxygen or air continously at low pressure into airway. ii. Prevents alveoli from

collapsing at end of

exhalation. iii. Can prevent fluid shifting into alveoli from

surrounding capillaries. b. Common uses i. Pulmonary edema. ii. Drowning. iii. Asthma and COPD. iv. Respiratory failure in general. c. Contraindications i. Severely alteres menta status ii. Lack of normal, spontanous respiratory rate. iii. Hypotension, shock. iv. Nausea and vomiting. v. Penetrating chest trauma . vi. Upper GI bleeding. vii. Conditions preventing good mask seal. d. Side effects i. Hypotension. ii. Pneumothorax. iii. Increased risk of aspiration. iv. Drying of corneas. e. Using CPAP i. Explain procedure to patient. ii. Start with low level CPAP. iii. Reassess frequently: 1) Mental status 2) Dyspnea 3) Vital signs iv. Raise CPAP level if no relief within a few minutes. v. If patient deterioraties, remove CPAP and ventilate with bag-mask.

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PREHOSPITAL EMERGENCY CARE

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YOU started this course by studying Basic Life Support.

We cannot overemphasize the reason for designing this course, which is to save lives. And in a country like the Philippines where heart attack and stroke as one of the top three killers, you must be an expert in cardiovascular issues to truly be a lifesaver.

According to the Philipine Heart Association, heart attack and stroke strike more than half of their victims by sudden death — 276 die from heart attack every day while stroke claims the life of one Filipino every minute.

Heart attack comes without warning. In many cases, the first sign of heart disease is a sudden cardiac death which happens within one to 60 minutes from the onset of symptoms. This is the reason why a significant percentage of those who died from heart attack were not aware of their risk.

This chapter, therefore, is a very important component of your training as an EMT, next only to the Basic Life Support. In this chapter you will learn about the cardiovascular system, the factors that affect this system, and the conditions that you would eventually address when you become an EMT. Discussed also in more detail in this chapter is the automated external defibrillator (AED), its different types, and how to use it properly.

Master this chapter and you will surely be a lifesaver. And the best thing is the life you may save can be that of your immediate family member or friends.

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DAY

13

Cardiac Emergencies Acute Coronary Syndrome Causes of Cardiac Conditions Automated External Defibrillation

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monary resuscitation (CPR) can help postpone death for a short time, bu brillation must be performed as quickly as possible Defibrillation, which w covered in the second part of this chapter, is the application of an elec shock to the chest in order to restart the heart's normal action Cardiac ar a situation in which you may actually be able to save someone's life by a PRINCIPLES OF EMT CLINICAL PRACTICE Day 13 quickly and efficiently.

CARDIAC EMERGENCIES

CARDIAC ANATOMY AND PHYSIOLOGY

LEARNING OBJECTIVES • Describe the structure and function of the cardiovascular system.

• Describe and demonstrate the assessment on emergency medical care of the patient experiencing chest pain/discomfort.

• List the indications, contraindications and side effects for the use of nitroglycerin.

• Define the role of EMT B in the emergency cardiac care system.

• List signs and symptoms of acute coronary syndromes including angina and AMI.

CROSS SECTION OF THE HEART

INTRODUCTION

² Limmer, O’Keefe, “Emergency Care”, 12th Edition. Brady, NJ (2012) As a future EMT, you will often encounter ³ Pollack, “Emergency Care and Transport of Sick and Injured”, 10th Edition. AAOS, MS (2011) ⁴ National Highway and Traffic Safety Administration (NHTSA), “EMT Basic Standard Curriculum“, Department of Transportation, USA patients who complain of chest discomfort.

Sometimes this discomfort will be the result of a cardiac (heart) problem, possibly a heart attack, some other cardiac disorder. You must be able YOU LEARNED ABOUT to provide these patients with oxygen, which is the most important drug in the treatment of heart problems- You must also be able to • Composition of the blood (red and while blood cells, assist patients with taking nitroglycerin and platelets, and plasma) aspirin. Most patients with chest pain will not • Flow of blood through the arteries, veins, arterioles, be having heart attacks. In fact, they may not venules, and capillaries, and the names and positions of have a heart problem at all Nonetheless, oxygen major blood vessels will not harm patients who are not having heart • Circulation of blood between the heart and the lungs and problems and may be of benefit to those who are. between the heart and the rest of the body Occasionally, you will encounter a • How heart function and the circulation of blood relate to patient who is in cardiac arrest—whose pulse (review the peripheral and central pulses) and blood normal heartbeat and circulation of blood pressure (review systolic and diastolic pressure. have completely stopped. Cardiopulmonary • Shock (hypoperfusion) resuscitation (CPR) can help postpone death for a short time, but defibrillation must be performed as quickly as possible Defibrillation, which will be covered in the second part of this “ chapter, is the application of an electrical shock to the chest in order to restart the heart’s normal action. Cardiac arrest is a situation in which you may actually be able to save someone’s life by acting quickly and efficiently.

CARDIAC ANATOMY AND PHYSIOLOGY

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NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe. Used with permission from Pearson Education, the publisher of the book.

ut defiwill be ctrical rrest is acting

A, (2005)

DAY 13

PRINCIPLES OF EMT CLINICAL PRACTIC

You learned about  Composition of ihc Wood (red and while blood cells, platelets, and plasma) cardiovascularnot complain of difficulty in breathing, specifically ask him system Acute coronary syndrome (ACS), sometimes called cardiac compromise, is a blanket term that refers to any time about it. Sometimes the pain is so intense that patients focus  Flow of blood throughtheir attention on that and do not mention other important the arteries, veins, arterioles, venules, and capi the heart may not be getting enough oxygen. There are many laries, and the names and positions of major blood vessels different ways in which patients’ hearts show that they are in symptoms. trouble. One reason for this is that there are many different A patient with ACS is often anxious. In some patients,  Circulation of blood between the heart and the lungs and between kinds of problems the heart can experience. A coronary this takes the form of a feeling of impending doom, which artery may become narrowed or blocked, a one-way valve the patient may express to you or others. Occasionally, you heart and the rest of the body may stop working properly, or the specialized tissue that will see a patient whose anxiety displays itself through irrita How heart function and the circulation of blood relate to pulse (rev carries electrical impulses may function abnormally. bility and a short temper.

Just as there are many different problems the heart Other common symptoms in patients with cardiac the peripheral and central pulses) and blood pressure (review syst can experience, there is a very wide variety of signs and compromise are nausea and pain or discomfort in the upper and diastolic pressure.abdomen (epigastric pain). Some of these patients also symptoms associated with these problems. Most of these signs and symptoms can also result from problems that  Shock (hypoperfusion)vomit. A less common finding is loss of consciousness. This

ACUTE CORONARY SYNDROME

have nothing to do with the heart. Many patients with heart may result from the heart beating too fast or too slow to trouble will complain of pain in the center of the chest. adequately supply the brain with oxygenated blood. Usually, Others may have only mild chest discomfort or no pain at the patient regains consciousness quickly.

You may also wish to review the diagrams of the heart, the cardiovascular syst all, Some may experience difficulty breathing, while still There are also several signs you will see in some of the cardiac conductive system,these patients, including the sudden onset of sweating and and the circulatory system in topics, "Medical T others have only the sudden onset of sweating, nausea, and vomiting. an abnormal pulse or blood pressure. Many patients who minology and Anatomy and Physiology."

Since the signs and symptoms of a heart problem can have sudden onset of sweating think they are coming down vary so greatly, it is much safer for the EMT to treat all with the flu, but this may result from the denial that is patients with certain signs and symptoms as though they are common in these patients. They refuse to acknowledge, at having a heart problem—ACS—instead of having to decide least consciously, that they may be having heart problems. whether or not the patient has a particular type of heart The pulse may be abnormally slow (slower than 60 beats per problem. Some common cardiovascular disorders will be minute, called bradycardia) or abnormally fast (faster than discussed later in this chapter to assist you in recognizing 100 beats per minute, called tachycardia) and will frequently and treating the symptoms associated with such disorders. be irregular. Some patients complain of palpitations, which Definitive diagnosis and care will be provided at the hospital.

The best known symptom of a heart problem is chest pain. Typically, a patient describes this THE CORONARY pain as crushing, dull, heavy, or squeezing.

ARTERIES Sometimes the patient will vehemently deny having pain but may admit to some pressure.

Some patients will describe this sensation as just a discomfort. This is a good example of why you should have a patient describe in his own words how he is feeling. If you ask some of these patients whether they are having chest pain, they will tell you they are not, because to them it is not pain. When a patient is having difficulty describing the sensation, try suggesting several choices, as you learned in the topic, “Assessment of the Medical Patient.”

The pain, pressure, or discomfort associated with cardiac compromise commonly radiate along the arms, down to the upper abdomen, or up to the jaw. Patients complain of radiation to the left arm more than the right, but either (or both) is possible.

Another frequent complain (and sometimes the only complaint in a patient with cardiac compromise) is difficulty breathing, called dyspnea. If the patient does

ACUTE CORONARY SYNDROME

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Acute coronary syndrome (ACS), sometimes called cardiac compromise, is a b ket term that refers to any time the heart may not be gelling enough oxyg

Day 13

CARDIAC EMERGENCIES

are irregular or rapid heartbeats they feel as a fluttering sensation in the chest. A few patients arc hypotensive (systolic blood pressure less than 90). whereas other are hypertensive (systolic greater than 130 or diastolic greater than 90).

Patients with cardiac compromise have many different presentations. Most commonly, the patient complains of pressure or pain in the chest with difficulty breathing and a history of heart problems. Others may have just mild discomfort that they ignore for several hours or that goes away and returns. Between one-quarter and one-third do not have the typical presentation of chest discomfort.

This is especially true in older patients and women— women primarily because they are older when they have cardiac problems. In this case, you may see a patient who complains of difficulty breathing, sudden onset of sweating, or a sudden, unusual feeling of fatigue without chest discomfort. Because of these many possibilities and because of the potentially severe complications of heart problems, it is important to have a high index of suspicion and treat patients with any of these signs and symptoms for cardiac compromise. The treatment will not hurt them and may help them.

Management of Acute Coronary Syndrome PATIENT ASSESSMENT After performing your primary assessment, perform a history and physical exam. Get a history of the present illness by asking the OPQRST questions (inquire about onset, provocation, quality, radiation, seventy, and time) Also get a past medical history (allergies, medications the patient may betaking, pertinent past history, last oral intake, events leading to the present emergency) Then take baseline vital signs. The following signs and symptoms are often associated with ACS • Pain, pressure or discomfort in the chest ot upper abdomen (epigastrium) • Difficulty breathing • Palpitations • Sudden onset of sweating and nausea or vomiting • Anxiety (feeling of impending doom, irritability) • Unusual generalized weakness • Abnormal pulse (rapid, slow, or irregular) • Abnormal blood pressure

Although oxygen has never been proven to benefit “stable” patients with cardiac compromise this does not mean oxygen is useless. There are many interventions that have never been proven to help patients, but are felt by authorities and the healthcare community to have little risk and potentially significant benefits For example, no one has proven that direct pressure is a safe and effective means of controlling bleeding. The consensus is that, nonetheless, direct pressure is the first and most important step in controlling hemorrhage. Similarly, the traditional teaching has been to administer oxygen to any patient, even a stable one, with potential cardiac compromise.

Another reason to administer oxygen to these patients is the difficulty of determining who is “stable”. It is often easy to tell that some patients are unstable, like the elderly man clutching his chest who has cyanosis around his lips and in his nail beds. It is much more difficult, and sometimes impossible, to determine definitively that a patient is stable, so the best thing to do is generally to administer oxygen to the patient with potential cardiac compromise.

If the patient already has a normal reading on the pulse oximeter while breathing room air, has stable vital signs, and has vague or unclear symptoms that might or might not be associated with cardiac compromise, many EMS

Follow these steps for the emergency care of a patient with suspected ACS 1. Place the patient in a position of comfort, typically sitting up. This is especially true of patients with difficulty breathing. Patients who are hypotensive (systolic blood pressure less than 90) will usually feel better lying down. This position allows more blood to flow to the brain. Occasionally, you will see a patient who has both difficulty breathing and hypotension. It may be very difficult to find a good position in this case. The best way to determine the proper position is to ask the patient what position will relieve his breathing difficulty without making him weak or lightheaded.

2. Apply high-concentration oxygen through a nonrebreather mask if not already done. This is especially important if the patient is hypoxic, as reflected in his signs and symptoms, including the oxygen saturation level. Keep the patient’s oxygen saturation at a level of at least 95 percent.

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systems recommend providing high-concentration oxygen by nonrebreather mask, although some may allow EMTs to give low-concentration oxygen by means of a nasal cannula. This is an area that needs further study, so follow your local protocols.

If the patient has or develops an altered mental status, you will need to open and maintain the patient’s airway. If the patient is not breathing adequately, you will also need to ventilate him. Always be prepared for the patient to go into cardiac arrest.

Transport immediately if the patient has any one of the following: • No history of cardiac problems.

• History of cardiac problems, but does not have nitroglycerin.

• Systolic blood pressure below 90 to 100.

Assist or give the patient (or help the patient take) nitroglycerin if all of the following conditions are met: • Patient complains of chest pain.

• Patient has a history of cardiac problems.

• Patient’s physician has prescribed nitroglycerin.

• Patient has the nitroglycerin with him.

• Systolic blood pressure meets your protocol criteria (usually greater than 90 to 100 systolic).

• Patient has not taken Viagra or a similar drug for erectile dysfunction within 48 to 72 hours.

• Medical direction authorizes administration of the medication.

After giving one dose of the nitroglycerin, give a repeat dose in 5 minutes if all of the following conditions are met: • Patient experiences no relief or only partial relief.

• Systolic blood pressure remains greater than 90 to 100 systolic.

• Medical direction authorizes another dose ol the medication.

If you are trained, equipped, and authorized to do so, obtain a 12-lead electrocardiogram (ECG). Follow local protocol with regard to whether you should transmit it to a hospital or physician for interpretation. Determining whether the patient has an ST-elevation myocardial infarction (STEMI) may be extremely important in Administer a maximum of three dose of nitroglycerin, determining the kind of treatment the patient may benefit reassessing vital signs and chest pain after each dose If from and where you will transport the patient. the blood pressure falls below 90 to 100 systolic, treat the In areas with more than one hospital, there may be patient for shock (hypoperfusion). Transport promptly. one or two facilities with special treatment available for Give the patient (or help the patient take) aspirin if any of cardiac patients. Almost all hospitals can administer an the following conditions are met: intravenous drug to dissolve the clot that • Patient complains of chest is causing insufficient oxygenation of the pain.

MANAGING CHEST PAIN heart. A more effective way to unclog the • Patient is not allergic to coronary artery is to insert a catheter aspirin. with a balloon at the tip into the arterial 1. FIRST TAKE STANDARD • Patient has no history of system and thread it into the coronary PRECAUTIONS. asthma. arteries. When the balloon reaches 2. Perform the primary • Patient is not already the narrow section of the artery, it is assessment. taking any medications inflated, compressing the obstructive 3. Provide high-concentration to prevent clotting (Since material against the side of the blood oxygen by non breather mask. some of these patients. vessel and opening up circulation to Perform the history and may still benefit from the heart muscle again. This is called physical exam for a medical aspirin, consult your percutaneous coronary intervention patient. Document the local protocol or medical (PCI) and is often better than the “clot findings. direction in this case.) buster drug’ approach when it is done 4. If the patient meets • Patient has no other early (within a few hours of onset of nitroglycerin criteria and has contraindications to symptoms). Only hospitals with special prescribed nitroglycerin, ask aspirin. facilities and available staff can do this, him about the last dose taken.

• Patient is able to swallow however. If your EMS system has the 5. Check the five rights: right without endangering the ability to transport patients to a hospatient, right time, right drug, airway. pital with this capability, there will be right dose and right route.

• Medical direction a local protocol that you should follow Check the expiration date. authorizes administration describing when, where, and how you Follow local protocols and of the medication. should transport patients with certain consult medical direction signs and symptoms before assisting the patient with taking medication.

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NITROGLYCERIN Medication Name

1. Generic: nitroglycerin 2. Trade: Nitrostat, Nilrolingual

Medication Form—

Tablet, sublingual (under-thetongue) spray

Dosage—One dose.

Repeat in 5 minutes, if less than complete relief, if systolic blood pressure remains above 90 to 100, and if authorized by medical direction, up to a maximum of three doses.

Administration

Indications

All the following conditions must be met: 1. Patient complains of chest pain.

2. Patient has a history of cardiac problems.

3. Patient’s physician has prescribed nitroglycerin (NTG).

4. Systolic blood pressure is greater than 90 to 100 systolic.

5. Medical direction authorizes administration of the medication.

1. Perform a focused assessment for the cardiac patient.

2. Take the patient’s blood pressure. (Systolic pressure must be above 90 to 100.)

3. Contact medical direction, if no standing orders.

4. Ensure the right patient, right time, right medication, right dose, and right route. Check the expiration date.

5. Ensure the patient is alert.

6. Question the patient on the last dose taken and effects. Ensure understanding of the route of administration.

7. Ask the patient to lift his tongue, and place the tablet or spray dose under the tongue (while wearing gloves) or have the patient place the tablet or spray under the tongue.

8. Have the patient keep his mouth closed with the tablet under the tongue (without swallowing) until dissolved and absorbed.

9. Recheck the patient’s blood pressure within 2 minutes.

10. Record the administration, route, and time.

11. Reassess the patient.

Contraindications

1. Patient has hypotension, or a systolic blood pressure below 90 to 100.

2. Patient has a head injury.

3. Patient is an infant or child.

4. Patient has already taken the maximum prescribed dose.

5. Patient has recently taken Viagra, Cialis, Levitra, or another drug for erectile dysfunction.

Actions

1. Relaxes blood vessels 2. Decreases workload of heart

Side Effects 1. Hypotension (lowers blood pressure) 2. Headache 3. Pulse rate changes

Reassessment Strategies 1. Monitor blood pressure.

2. Ask patient about effect on pain relief.

3. Seek medical direction before readministering.

4. Record assessments.

Bihirang-bihira sa mga bata ang may sakit sa puso, kaya naman bihirang-bihira din na may maging pasyente ang mga EMT na batang puso ang problema. Kung meron man, kadalasan ay congenital ito o simula pagkapanganak ay may problema na ang bata. May mga bata na nagkaroon na ng operasyon sa puso o kaya naman ay nabubuhay na lamang dahil sa gamot at pag-aalaga ng magulang. Importante na makausap ng EMT ang mga magulang ng mga ganitong pasyente para malaman nito ang mas malalim na sitwasyon.

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CAUSES OF CARDIAC CONDITIONS

“

Heart problems can be caused by a number of disorders that affect the condition and function of the Mood vessels and the heart. The majority of cardiovascular emergencies arc caused, directly or indirectly, by changes in the inner walk of arteries. These arteries can be part of the systemic (total body), pulmonary (lung), or coronary (heart) circulatory systems. Problems with the heart's electrical and mechanical functions also cause cardiovascular emergencies.

CAUSES OF CARDIAC Coronary CONDITIONS Artery Disease

The heart is a muscle—a very acHeart problems can be caused by a number of tive muscle. Like all other muscles, disorders that affect the condition and function of the it needs oxygen to contract. The blood vessels and the heart. The majority of cardiovasblood that is pumped through cular emergencies arc caused, directly or indirectly, by the chambers of the heart does changes in the inner walk of arteries. These arteries can not provide oxygen to the heart be part of the systemic (total body), pulmonary (lung), itself, Instead, the heart muscle is or coronary (heart) circulatory systems. Problems with supplied with oxygenated blood the heart’s electrical and mechanical functions also by special blood vessels: the corocause cardiovascular emergencies. nary arteries.

When the coronary arteries are narrowed or blocked, blood flow is reduced, thereby reducing the amount of oxygen delivered to the heart. This might not be noticed when the body is at rest or at a low activity level. However, when the body is subject to stress or exertion, the heart rate (beats per minute) increases.

With the increased heart rate comes an increased need for oxygen. Arteries that are narrowed or blocked cannot supply enough blood to meet the heart’s demands.

Conditions that narrow or block the arteries of ² Limmer (Brady) the heart are commonly called coronary artery disease ³ Pollack, (AAOS) ⁴ NHTSA (CAD), Coronary artery disease is a serious health problem that results in hundreds of thousands of deaths yearly in the Philippines.

CAD is often the result of the build up of fatty deposits on the inner walls of arteries. This build up causes a narrowing of the inner vessel diameter, restricting the flow of blood. Fats and other particles combine to form this deposit, known as plaque. As time passes, calcium can be deposited at the site of the plaque, causing the area to harden.

This restricts the amount of blood passing through the artery. The rough surface formed inside the artery can facilitate formation of blood clots, which narrow the artery even more. The clot and debris from the plaque form a thrombus. A thrombus can reach a size where it causes an occlusion (cutting off) of blood flow, or it may break loose to become an embolism and move to occlude the flow of blood somewhere downstream in a smaller artery. In cases of partial or complete blockage, the tissues beyond the point of blockage will be starved of oxygen and may die. If this blockage involves a large area of the heart (as in a heart attack) or the brain (causing one kind of stroke), the results may be quickly fatal.

Some factors that put a personal risk of developing CAD. such as heredity (a close relative who has CAD) and age, cannot be changed. However, there are also many risk factors that can be modified to reduce the risk of coronary artery disease. These include hypertension (high blood pressure), obesity. lack of exercise, elevated blood levels of cholesterol and triglycerides, and cigarette smoking.

THE CORONARY ARTERIES

Coronary Artery Disease The heart is a muscle—a very active muscle. Like all other muscles, it needs oxygen to contract. The blood that is pumped through the chambers of the heart does not provide oxygen to the heart itself, Instead, the heart muscle is supplied with oxygenated blood by special blood vessels: the coronary arteries.

Many patients have more than one of these risk factors. Fortunately, the damage caused by the second group of risk factors may be reversed or slowed by changing behavior. Smokers can return to the risk level of a non-smoker soon after quitting. Medication and weight loss can lower high blood pressure. Improved diet and exercise can help the other controllable factors.

In the majority of cardiac-related medical emergencies, the reduced blood supply to the myocardium (heart muscle) causes the emergency.

The most common symptom of this reduced blood supply is chest pain. Patients may have symptoms that range anywhere from mild chest pain to cardiac arrest. Angina pectoris (chest pain), acute myocardial infarction (heart attack), and congestive heart failure— all conditions that can be related to CAD—are discussed later in this chapter.

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DAY 13

PRINCIPLES OF EMT CLINICAL PRAC CARDIAC EMERGENCIES Aneurysm

Day 13

Aneurysm Another cause of cardiovascular system disorder stems from weakened sections in the arterial walls. Each weak spot that begins to dilate (balloon) is known as an Another cause of cardiovascular system disorder stems from weakened secaneurysm. This weakening can be related to other arterial tions in the arterial walls. Each weak spot that begins to dilate (balloon) is diseases, or it can exist independently. When a weakened known as an aneurysm. This weakening can be related to other arterial dissection of an artery bursts, there can be rapid, lifeeases, or it can exist independently. When a weakened section of an artery threatening internal bleeding. Tissues beyond the rupture bursts, there can be rapid, life-threatening internal bleeding. Tissues beyond can be damaged because the oxygenated blood they need is the rupture can he damaged because the oxygenated blood they need is esescaping and not reaching them. If a major artery ruptures, caping and not reaching them. If a major artery ruptures, death from shock death from shock can occur very quickly. The two most common sites of aneurysms that you will encounter in can occur very quickly. The two most common sites of aneurysms that you will emergency situations are the aorta and the brain. When an encounter in emergency situations are the aorta (see topic, "Abdominal Emerartery in the brain ruptures, a severe form of stroke occurs. gencies') and the brain (sec topic, "Diabetic Emergencies and Altered Mental The severity is dependent on the site of the stroke and the Status"). When an artery in the brain ruptures, a severe form of stroke occurs. amount of blood loss.

The severity is dependent on the site of the stroke and the amount of blood loss.

Electrical Malfunctions of the Heart

Electrical MalfunctionsAnother cause of cardiovascular system disorder stems from weake of the Heart

CONDUCTION SYSTEM Electrical impulses generated tions in within the arterial walls. Each weak spot that begins to dilate (ba the heart are responsible fur the known as an aneurysm. This weakening can be related to other art heart's rhythmic beating that pumps eases, or can exist independently. When a weakened section of a Electrical impulses generated within the heart are blood throughout the body.

A itmalresponsible for the heart’s rhythmic beating that pumps bursts, there can be rapid, life-threatening internal bleeding. Tissues function or The heart's electrical sysblood throughout the body. A malfunction of the heart’s the rupture can tem will generally result in a dysrhyth- he damaged because the oxygenated blood they ne electrical system will generally result in a dysrhythmia, an mia, an irregular, or absent, heart caping and not reaching them. If a major artery ruptures, death from irregular, or absent, heart rhythm. Dysrhythmias include rhythm. Dysrhythmias include bradybradycardia (abnormally slow, less than 60 beats per minute), can occur very quickly. The two most common sites of aneurysms that cardia (abnormally slow, encounter less thanin60 tachycardia (abnormally fast, greater than 100 beats per emergency situations are the aorta (see topic, "Abdomin minute), and rhythms that may be present when there is no beats per minute), tachycardia gencies') and the brain (sec topic, "Diabetic Emergencies and Altered pulse (in cardiac arrest) including ventricular fibrillation, (abnormally fast, greater than 100 Status"). When ventricular tachycardia, pulseless electrical activity, and beats per minute), and rhythms that an artery in the brain ruptures, a severe form of stroke asystole (described later in this chapter). The severity is dependent on the site of the stroke and the amount o may be present when there is no loss. pulse (in cardiac arrest) including ventricular fibrillation, ventricular tachycardia, pulseless electrical activity, and Malfunctions of the Heart asystole (described later Electrical in this chapter).

Another complication sometimes seen with a

Mechanical Malfunctions of the Heart

Electrical impulses generated within myocardial infarction, or heart attack, is mechanical the heart are responsible fur the pump failure. In this situation, a lack of oxygen causes the Nagiging dahilan din death of a portion of the myocardium. The dead area can heart's rhythmic beating that pumps ng problema sa puso ang no longer contract and pump. If a large enough area of the blood throughout the body.

A malpagkasira o pagkakaroon ng heart dies, the pumping action of the whole heart will be diprensya ng mga balbula function or The heart's electrical sysaffected. This can lead to cardiac arrest, shock, pulmonary ng puso. Dito kadalasan edema (fluids “backing up” in the lungs), or congestive tem will generally result in a dysrhythnagmumula ang pagbabara heart failure (discussed later in this chapter). A few heart mia, an irregular, or absent, heart sa puso. attack patients suffer cardiac rupture as the dead tissue ² Limmer (Brady) rhythm.

Dysrhythmias include bradyarea of the heart muscle bursts open. This occurs days after ³ Pollack, (AAOS) a heart attack. ⁴ NHTSA cardia (abnormally slow, less than 60

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beats per minute), tachycardia (abnormally fast, greater than 100 beats per minute), and rhythms that may be present when there is no pulse (in cardiac arrest) including ven-

CTICE

ened secalloon) is terial disan artery beyond eed is esm shock t you will nal Emerd Mental e occurs. of blood

Angina Pectoris Angina pectoris means, literally, a pain in the chest. In this condition, coronary artery disease has narrowed the arteries that supply the heart. During times of exertion or stress, the heart works harder. The portion of the myocardium supplied by the narrowed artery becomes starved for oxygen. When the myocardium is deprived of oxygen, chest pain—angina pectoris—is the most frequent result. This pain is sometimes called an angina attack.

Since the pain of angina pectoris comes on after stress or exertion, the pain will frequently diminish when the patient stops the exertion. As the oxygen demand of the heart returns to normal, the pain subsides.

Seldom does this painful attack last longer than 3 to 5 minutes.

Possession of nitroglycerin is another indication that the patient has a history of this condition. Nitroglycerin is a medication that dilates the blood vessels. This results in more blood staying in the veins of the body, so there is less blood coming back to the heart. With less blood to pump out. the heart does not have to work as hard.

Nitroglycerin is available in tablets that are placed under the patient’s tongue to dissolve, as well as sprays and patches. The patches have adhesive that keeps them on the skin .They gradually release nitroglycerin throughout the day.

Most angina patients are advised by their doctors to take nitroglycerin for their chest pain. Patients are usually told to rest and are allowed to take three nitroglycerin doses over a 15-minute period. If there is no relief of symptoms after that time, they are instructed to call for help.

Acute Myocardial Infarction The condition in which a portion of the myocardium (heart muscle) dies as a result of oxygen starvation is known as acute myocardial infarction (AMI). Often called a heart attack by laypersons. AMI is brought on by the narrowing or occlusion of the coronary artery that supplies the region with blood. Rarely, the interruption of blood flow to the myocardium may be due to the rupturing of a coronary artery (aneurysm).

Over a million cases of AMI occur in the Philippines each year and cardiovascular disease causes hundreds of thousands of deaths annually. A major portion of these deaths are cases of sudden death, a cardiac arrest that occurs within 2 hours of the onset of symptoms.

In most cases sudden death occurs outside of hospitals. The patient may have no prior symptoms of coronary artery disease. Nearly 25 percent of these individuals have no previous history of cardiac problems.

A variety of factors can cause an AMI. Coronary artery disease is usually the underlying reason for the incident. However, for some patients, factors often regarded as harmless, such as chronic respiratory problems, unusual exertion. or severe emotional stress may trigger an AMI. The treatment of AMI has changed radically over recent years. Previously,

patients were admitted to coronary care units where they were observed and, when emergencies occurred, treated with varying degrees of success. Now some patients receive treatment with medications called fibrinolytics to dissolve the clot that is blocking the coronary artery. To be most effective, these medications must be administered early. With each hour that passes before they are administered, they become less and less likely to dissolve the clot. As noted earlier, an even more effective way to unclog the coronary artery is to insert a catheter with a balloon that can be inflated to reopen circulation to the heart, a procedure known as balloon angioplasty or balloon catheterization.

Many patients with myocardial infarctions are not candidates for these treatments, but those who are must reach the hospital quickly.

A patient who leaves the hospital after an AMI will usually be told to take aspirin every day to prevent another episode. He will also probably be told to take a medication known as a beta blocker. This group of medication slows the heart and makes it beat less strongly. This would not usually be considered a good thing, but in these patients it results in a decrease in the work the heart has to do. This actually benefits the heart and leads to longer and better lives for these patients.

Congestive Heart Failure Congestive heart failure (CHF) is a condition of excessive fluid build up in the lungs and/or other organs and body parts because of the inadequate pumping of the heart.

The fluid build up causes edema or swelling. The disorder is traditionally termed congestive because the fluids congest, or clog, the organs. It is termed heart failure because the congestion both results from and also aggravates failure of the heart to function properly. The congestion may also result from and aggravate failure of the lungs to function properly.

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DAY 13

Day 13

CARDIAC EMERGENCIES

Congestive heart failure may he brought on by diseased heart valves, hypertension, or some form of obstructive pulmonary disease such as emphysema. CHF is often a complication of AMI. Congestive heart failure often progresses as follows: 1. A patient sustains an AMI. Myocardium in the area of the left ventricle dies (Recall the function of the heart. The left is the side of the heart that receives oxygenated blood from the lungs and pulmonary circulation and pumps it to the rest of the body.)

2. Because of the damage to the left ventricle, blood backs up into the pulmonary circulation and then the lungs. Fluid accumulation in the lungs is called pulmonary edema This edema causes a poor exchange of oxygen between the lungs and the bloodstream, and the patient experiences shortness of breath, or dyspnea. Listening to this patient’s lungs with a stethoscope may reveal crackling or bubbly lung sounds called crackles (rales). Some patients cough up bloodtinged sputum from their lungs.

3. Left heart failure, if untreated, commonly causes right heart failure.

The right side of the heart (which receives blood from the body and pumps it to the lungs) becomes congested because the clogged lungs cannot receive more blood. In turn, fluids may accumulate in the dependent (lower) extremities, the liver, and the abdomen.

Accumulation of fluid in the feet or ankles is known as pedal edema The abdomen may become noticeably distended. In a bedridden patient, fluid collects in the sacral area of the spine.

The CHF patient is probably on several medications for this condition. Often patients will tell you that they take a water pill for fluid build up. This refers to a diuretic, a medication that helps remove fluid from the circulatory system. Other medications may decrease the heart’s workload, leading to improvement in the patient’s condition.

CARDIAC ARREST In a typical ambulance service, only 1 to 2 percent of emergency calls are cardiac arrests. Further more, most patients with heart problems do not go into cardiac arrest while they are under your care. Nonetheless, EMS systems exert a great deal of time and energy on attempts to resuscitate these patients The odds of bringing a cardiac-arrest patient back to life have increased considerably over the last 15 or 20 years.

As the problem of cardiac arrest has received more attention.

EMS researchers, physicians, administrators, and providers have learned more about what is effective and what is not.

The signs and symptoms of CHF may include: • Tachycardia (rapid pulse. 100 beats per minute or more) • Dyspnea (shortness of breath) • Normal or elevated blood pressure • Cyanosis • Diaphoresis (profuse sweating), or cool and clammy skin • Pulmonary edema, sometimes coughing up of frothy white or pink sputum • Anxiety or confusion due to hypoxia (inadequate supply of oxygen to the brain and other tissues) caused by poor oxygen/ carbon dioxide exchange • Pedal edema • Engorged, pulsating neck veins (late sign) • Enlarged liver and spleen, with abdominal distention (late sign)

Immedia

Immediate one collap gets EMS r done. The gencies. It they shoul make the c

Many area have seven remember. many phon directories, call for hel grams that bers on th telephones available fr

Early CP

An EMS system where each of these links is strong is much more likely to bring back a patient from cardiac arrest than a system with weaknesses anywhere along the chain. This has been shown in systems that tried to strengthen just one link (early defibrillation) without strengthening the other links.

An underlying theme of the chain of survival is teamwork. Although many of the actions you should take to resuscitate someone are described as though you are alone or working with very little help, you will usually have at least one other person, if not more, to work with you. It is essential that you and your teammates work together in a coordinated fashion to maximize the chance of your patient’s survival. The need for teamwork also extends to others beyond the first ambulance Early CPR “ crew at the scene, including ALS teams, Emergency Medical Responders. public safety officers, emergency department physicians and staff, cardiac catheterization help is whe lab staff, and others. or less. Sinc Because so many people are working to help the patient, it is not only factor. The possible, but desirable, for many things to happen simultaneously or nearly simultaneously. There must be coordination for these combined activities to work CPR-trained in the patient’s favor. Having clear expectations that everyone is aware of goes a dispatchers long way toward achieving that goal. This will allow simple things like primary assessment to be more efficient as one person checks the pulse and another gets An efficien equipment ready and positioned properly. It also allows complex activities such as getting the patient to the cardiac catheterization lab at the right time so that trained pro the appropriate people are present and prepared This teamwork is essential to the officers, or success of a resuscitation effort and EMTs are a vital part of it. possible ne

place so th

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Some EMS information portant to school stud

ate Recognition and Activation

e recognition and activation means that the person who sees somepse or finds someone unresponsive calls a dispatcher who quickly responding to the emergency. Unfortunately, this is easier said than lay public, unlike EMS providers, are not used to recognizing emerImmediate recognition and activation means that the person who sees somelakes longer for them to realize that an emergency exists and that The Philippine Heart ld call for Association has summarized help right away. Even when one collapse or finds someone unresponsive calls a dispatcher who quickly gets a layperson does decide to EMS responding to the emergency. Unfortunately, this is easier said than done. The the most important factors that call for help, there may still be obstacles. lay public, unlike EMS providers, are not used to recognizing emergencies. It takes

Chain of Survival

Immediate Recognition and Activation

affect survival of cardiac arrest longer for them to realize that an emergency exists and that they should call for help patients in its chain of survival right away. Even when a lay people does decide to make the call for help, there may as still do not have 911 service. This means that emergency services concept. The chain has five still be obstacles. elements: numbers that laypeople n digit telephone cannot he expected to Many areas still do not have emergency numbers. This means that emergency 1.

Immediate recognition and . Even though services have seven digit telephone numbers that lay people cannot he expected to activation. ne companies list emergency numbers on the inside cover of their remember. Even though many phone companies list emergency numbers on the 2. Early CPR inside cover of their directories, this adds an extra step to the process and delays , this adds 3. anRapid defibrillation extra step to the process: and delays even further the even further the call for help. Many EMS agencies in this position base public 4. Effective advanced life lp. Many EMS agencies in this position base public information proinformation programs that include the distribution of telephone stickers with t include the support, and distribution of telephone stickers with emergency numemergency numbers on them. Since many Filipinos change residence frequently 5. Integrated post-cardiac a hem. Since Americans change residence(and buy new telephones more often than that), emergency services must make these frequently (and buy new nest care. stickers available frequently and easily. s more often than that), emergency services must make these slickers

requently and easily.

PR

Early CPR

Early CPR can increase survival significantly. About the only time it does not help is when defibrillation reaches the patient after approximately 2 minutes or more. Since this rarely happens in real life, EMS agencies need to address this factor. There are at least three ways in which CPR can be delivered earlier: Get CPR-trained professionals to the patient faster; train lay people in CPR; and train dispatchers to instruct callers in how to perform CPR. An efficient way to get CPR to patients faster in many areas is to send CPR-trained professionals to the scene. This may mean police, fire fighters, security officers, or lifeguards. These professionals need to receive notification of the possible need for CPR as soon as possible. They also need to be in the right place so they can respond quickly to where they are needed.

Some EMS agencies have CPR courses for the lay public as part of their public information and education programs, but too many do not. It is especially important to train the right lay people.

Teaching CPR to elementary and high school students is good, especially in the long run. but these students are not usually present when someone goes into cardiac arrest. The typical cardiac arrest patient is a can increase survival significantly.

About the only lime it does not Kadalasan ng male in his 60’s. So it is not surprising to learn that the typical witness of en defibrillation reaches the patient within nangangailangan ng CPR ay approximately 2 minutes a cardiac arrest is a woman in her 60’s, too. Middle-age and older people mga lalaki na edad 60 ce this rarely happens in real life. EMS agencies need to address this need CPR courses at least as much as children and adolescents. pataas. Mas madalas ere are at least three waysnainang which CPR can be delivered earlier: get A surprisingly effective way to get a lay people to perform CPR kasama nila is for a dispatcher to instruct the caller over the phone. This has been d professionals lo the patient faster, train laypeople in CPR. and train ay ang kanilang asawa done in a number of areas and has produced significant increases in the s to instruct callers in how lo perform CPR. na ganun din ang edad. survival rate from cardiac arrest. The quality of CPR done by untrained Kaya naman importante lay people instructed by dispatchers is comparable to CPR done by lay na matuto rin ng CPR ang nt way to get CPR to patients faster in many areas is lo send CPRpeople who were previously trained in CPR. This appears to be true even mga matatanda dahil sila when lay people perform chest compressions without ventilating the ofessionals to the scene.

This may mean ang puwedeng magligtas sa police, fire fighters, security r lifeguards. These professionals need notification of the kanilang mahal sa buhay.to receivepatient. Emergency Medical Dispatchers (EMDs) are trained to give such instructions. Prearrival dispatch instructions are available to guide other eed for CPR as soon as possible. They also need to be in the right dispatchers in this step.

hey can respond quickly to where they are needed.

agencies have CPR courses for the lay public as part of their public n and education programs, but too many do not. It is especially imtrain the right laypeople. Teaching CPR to elementary and high dents is good, especially in the long run. but these students are not

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rest. The quality of CPR done by untrained laypeople instructed by disers is comparable to CPR done by laypeople who were previously trained . This appears to be true even when laypeople perform chest compreswithout ventilating the patient. Emergency Medical Dispatchers (EMDs) CARDIAC EMERGENCIES Day 13 instructions ined to give such instructions. Prearrival dispatch are availo guide other dispatchers in this step.

d Defibrillation

Rapid Defibrillation

Early defibrillation has received a great deal of attention because it is the single most important factor in determining survival from cardiac arrest. Although a lot of emphasis has been put on defibrillation, there is often not enough attention paid to early defibrillation. With a few thousand pesos or less, an agency can purchase an automated defibrillator. The hard part is getting this equipment to the patient in cardiac arrest early enough to be effective, If the response time of the defibrillator (time from call received to arrival of the defibrillator) is longer than 10 minutes, virtually no patients survive cardiac arrest. This is often true even if early CPR is performed. Although 8 minutes is really the maximum response time for effective defibrillation, the sooner the defibrillator arrives, the more likely it is that a patient will survive cardiac arrest. In this case, it is literally true that every minute counts.

One way to get around long ambulance response times is to provide defibrillators to other emergency services providers. Some EMS systems have used innovative ways to make sure that a defibrillator arrives in time. In urban and suburban areas, for example, police officers and fire fighters efibrillation has received a great deal of attention because it is the single have sometimes been equipped with the machines since they may arrive on scene before the mportant factor in determining survival from cardiac arrest. Although a ambulance. In rural areas, some EMTs and Emergency Medical Responders carry defibrillators emphasis has been put on defibrillation, there is often not enough attenin their personal vehicles so that the patient who needs a defibrillator gets it in time. aid to early defibrillation. With a few thousand dollars or less, an agency Another way to get defibrillation to patients earlier is to have non-traditional responders urchase an automated defibrillator.

The hard part is getting this equipuse them. There are well-documented cases where non-emergency responders have resuscitated patients in cardiac arrest. These cases share certain characteristics: Patients or potential to the patient in cardiac arrest early enough lo he effective, If the ree time of the defibrillator (timepatients are under constant observation so that a witnessed arrest can be detected and reported from call received to arrival of the defibrilimmediately (e.g., in an airport terminal or a casino), the responders are employees who receive s longer than 8 minutes, virtually no patients survive cardiac arrest. This initial and refresher training in CPR and use of an AED (e.g.. flight attendants or security n true even if early CPR is performed.

Although 8 minutes is really the officers), and the areas in which the employees and AEDs are deployed are high volume or high risk areas where cardiac arrests occur on a regular basis. Training lay people to use an AED and um response lime for effective defibrillation, the sooner the defibrillator administer CPR has become very popular and may have the potential to improve survival from , the more likely it is that a patient will survive cardiac arrest. In this case, cardiac arrest.

rally true that every minute counts.

Effective Advanced Life Support

way to get around long ambulance response limes is lo provide defibrillaother emergency services providers.

Some EMS systems have used innoEffective advanced life support is second only to defibrillation in the drama ways to make sure that a defibrillator arrives in lime. In urban and suburand excitement it stirs in lay people. Putting a breathing tube into someone’s throat (endotracheal intubation), pulling a needle into someone’s arm (starting an intravenous eas, for example, police officers and fire fighters have sometimes been line), and administering medications into an IV line are all activities that lay people may ped with the machines since they may arrive on scene before the ambunot understand, but they are actions that the public has come to expect. They may also lead In rural areas, some EMTs and Emergency Medical Responders carry to a higher survival rate. lators in their personal vehicles so that the patient who needs a defibrilThe most common way for patients to get advanced cardiac life support (ACLS) is through EMT-Paramedics who either respond to the scene or rendezvous with a ets it in time.

basic life support unit en route to the hospital. In some areas, there are EMTs who have more training than basic-level EMTs but less than paramedics. Their level of practice is er way to get defibrillation lofrequently called EMT-Cardiac, EMT-Critical Care, EMT-Intermediate, or Advanced EMT. patients earlier is to have non traditional nders use them. There are well-documented cases where nonemergency They may be able to perform interventions that can improve survival of these patients.

Another method that is not quite as fast is for EMTs to transport patients not to a hospital, nders have resuscitated patients in cardiac arrest. These cases share cerbut to a clinic or other medical facility that is closer. Any such arrangements need to he haracteristics; Patients or potential patients are under constant observamade before they are actually needed and should be in writing in the form of protocols. that a witnessed arrest can be detected and reported immediately (e.g., These protocols should be approved by your Medical Director.

airport terminal or a casino), the responders are employees who receive and refresher training in CPR and use of an AED (e.g.. flight attendants urity officers), and the areas in CARE which the employees and AEDs are de330 LIFELINE PREHOSPITAL EMERGENCY are high volume or high risk areas where cardiac arrests occur on a r basis. Training laypeople to use an AF.D and administer CPR has bevery popular and may have the potential to improve survival from carrest.

Integrated Post-Cardiac Arrest Care Integrated post-cardiac arrest care means coordinating numerous different means of assessment and interventions that, together, maximize the patient’s chance of neurologically intact survival. Elements of this approach include maintaining adequate oxygenation, avoiding hyperventilation, performing a 12-lead ECG. finding and managing treatable causes of the arrest, determining the appropriate destination for the patient, possibly inducing hypothermia, and several other advanced interventions.

As researchers continue to evaluate new interventions to improve cardiac resuscitation, they are also evaluating treatments to improve cerebral or brain resuscitation. Most patients who regain a spontaneous pulse after a short period of ventricular fibrillation wake up with little or no brain damage. Some patients, however, especially those who had prolonged down times, have significant brain damage that prevents them from returning to normal activities or even from regaining consciousness.

One intervention that appears to reduce brain damage in some resuscitated patients is controlled hypothermia. Cooling a patient ‘s body to around 90°F to 93”F (32°C to 34°C) and maintaining that temperature for up to 24 hours has led to more survivors and less brain damage than in patients who did not receive the treatment.

Although therapeutic hypothermia has improved neurologically intact survival, inducing it can be challenging. Different EMS systems have different approaches to this treatment, most involving advanced life support providers. If some of your local hospitals employ this treatment and others don’t, it may be appropriate to transport your post-cardiac arrest patient to a facility that can provide it. Follow your local protocols.

EMS systems that have immediate recognition and activation, early CPR. rapid defibrillation, effective advanced life support, and integrated post-cardiac arrest care have survival rates from cardiac arrest that are higher than systems w ith weaknesses in one or more of the links in the chain of survival.

Management of Cardiac Arrest As an EMT, you can provide two links in the chain of survival: early CPR and rapid defibrillation.

The rest of this chapter will emphasize the role of defibrillation in treating cardiac arrest patients. Managing a patient in cardiac arrest means you need to be able to: • Perform one- and two-rescuer CPR. Ordinarily, you will do two-rescuer CPR when you are on duty, but you must be able to perform one-rescuer CPR while your partner is preparing equipment or while you are en route to a medical facility.

• Use an automated external defibrillator.

• Request advanced life support (when available) to continue the chain of survival.

• Use a bag-valve-mask device with oxygen.

• Use a flow-restricted, oxygen-powered ventilation device.

• Lift and move patients.

• Suction a patient’s airway.

• Use airway adjuncts (oropharyngeal and nasopharyngeal airways).

• Take Standard Precautions to protect yourself (and patients).

• Interview bystanders and family members to obtain facts related to the arrest.

Kadalasan ng pasyente na makikita ninyong masakit ang dibdib at hirap huminga ay gising pa at nakakapagsalita kapag dinatnan ninyo. Pero ang iba ay puwedeng tumigil ang puso bago kayo makarating sa ospital.

Maging handa na magbigay ng CPR at defibrillation sa loob ng ambulansya.

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Automated External Defibrillator (AED) Types of AEDs

There are two ways someone can defibrillate.

The older method (manual defibrillation) is for the operator to look at the patient’s heart rhythm on a screen, decide the rhythm is shockable, lubricate and charge two paddles and deliver a shock to the patient’s chest. An automated defibrillator, in contrast, contains a computer that analyzes the patient’s heart rhythm after the operator applies two monitoring-defibrillation pads to the patient’s chest.

There are two types of automated external defibrillators: semiautomatic and fully automatic.

Semiautomatic defibrillators, the more common type, advise the EMT to press a button that will cause the machine to deliver a shock through the pads. Semiautomatic defibrillators are sometimes called “shock advisory defibrillators.”

Fully automated defibrillators do not advise the EMT to take any action. They deliver the shock automatically once enough energy has been accumulated. All the EMT has to do to use a fully automatic defibrillator is assess the patient, turn on the power, and put the pads on the patient’s chest.

The following information about how to operate an AED applies principally to a semiautomatic AED. Another way in which AEDs can be classified is by the type of shock they deliver. The traditional monophasic defibrillator sends a single shock (this is what monophasic means) from the negative pad or paddle to the positive pad or paddle. A biphasic defibrillator sends the shock in one direction and then the other. This kind of machine also typically measures the impedance or resistance between the two pads and adjusts the energy accordingly, delivering more energy when the impedance is higher and less when it is lower. These features allow biphasic AEDs to use less energy and perhaps cause less damage to the heart. Use of biphasic AEDs does not result in higher survival rates, but they are at least as good as monophasic machines and have other advantages. Because the battery doesn’t need to deliver as much energy, they are smaller and lighter than monophasic AEDs, a significant factor when an EMT has to carry several heavy pieces of equipment at once.

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How AEDs Work

Like all muscles, the heart produces electrical impulses. By putting two monitoring electrodes on the patient’s chest, it is possible to “synchronize” the heart’s electrical activity. An AED can analyze this cardiac rhythm and determine whether or not it is a rhythm for which a shock is indicated. The microprocessors and the computer programs used to do this have been tested extensively and have been very accurate, both in the laboratory and in the field. Today’s AEDs are very reliable in distinguishing between rhythms that need shocks and rhythms that do not need shocks.

When AEDs deliver shocks inappropriately, it is almost always the result of human error. This occurs because the operator did not assess the patient properly (AEDs are designed only for use on patients in cardiac arrest), did not use the AED properly, or did not maintain the machine. The chance of mechanical error is always present, but it is small. Maintaining the AED in good operating order; attaching an AED only to unresponsive, pulseless, nonbreathing patients; practicing frequently; and following your local protocols are the best ways to avoid making an error that could affect a patient.

Often, a cardiac event such as a spasm or blockage of a coronary artery (myocardial infarction or heart attack) is associated with a disturbance of the heart’s electrical, or conduction, system, which must function normally if the heart is to continue to beat with a regular rhythm. The most common conditions that result in cardiac arrest are shockable rhythms: • Ventricular fibrillation • Ventricular tachycardia The primary electrical disturbance resulting in cardiac arrest is ventricular fibrillation (VF). Up to 50 percent of all cardiac arrest victims will be in VF if EMS personnel arrive in the first 8 minutes or so. The heart in VF may have plenty of electrical energy, but it is totally disorganized. Chaotic electrical activity originating from many sites in the heart prevents the heart muscle from contracting normally and pumping blood. If you could see a heart in VF, it would appear to be quivering like a hag of worms.

VF is considered a “shockable rhythm,” that is, VF is a rhythm for which defibrillation is effective.

Automated external defibrillators are also designed to shock a rhythm known as ventricular tachycardia (V-tach) if it is very fast in ventricular tachycardia (an unusual cardiac arrest rhythm observed in less than 10 percent of all out-of-hospital cases), the heart rhythm is organized, but it is usually quite rapid. The faster

the heart rate, the more likely it is that ventricular tachycardia will not allow the heart’s chambers to fill with enough blood between beats to produce blood flow sufficient to meet the body’s needs, especially that of the brain. Pulseless V-tach is considered a shockable rhythm.

Some patients with ventricular tachycardia are awake, even with very fast heart rates. If an AED is attached to one of these patients, it will charge up and advise a shock. Since the patient has a pulse and is awake, this action would be inappropriate. This is one of the reasons the AED should be attached only to patients in cardiac arrest. Nonshockable rhythms include: • Pulseless electrical activity (PEA) • Asystole In 15 to 20 percent of cardiac arrest victims, the rhythm is called pulseless electrical activity (PEA): that is, the heart muscle itself fails even though the electrical rhythm remains relatively normal. This condition of relatively normal electrical activity but no pumping action means that the heart muscle is severely and almost always terminally sick. Or it may mean that the patient has lost too much blood. The heart could pump if it had something to pump, but there is no fluid in the system. Defibrillation cannot help these people because their heart’s electrical rhythm is already organized and slow (unlike ventricular tachycardia, where the rhythm is organized but very fast). PEA is not considered a shockable rhythm.

In the remaining 20 to 5O percent of cardiac arrest victims, the heart has ceased generating electrical impulses altogether. This condition is called asystole When this happens, there is no electrical stimulus to cause the heart muscle to contract, and so it does not.

As a result, there is no blood flow, and the patient has no pulse or respirations and is unconscious. This condition is commonly called flatline, because the wavy line displayed on an ECG when there is electrical activity goes flat with asystole. This condition can be the result of untreated ventricular fibrillation, a sick heart, a terminal illness, or severe blood loss. Asystole is not considered a shockable rhythm.

By adding up the numbers, you can see that automated defibrillators will shock, at most, only about 6 or 7 of every 10 cardiac arrest patients to whom they are attached: those suffering from the disturbed rhythms of ventricular fibrillation and ventricular tachycardia. For patients suffering from pulseless electrical activity (heart muscle failure) or asystole (complete lack of electrical activity), defibrillation will not be effective.

UNIT 3 DAY 13

Coordinating CPR and AED for a Patient in Cardiac Arrest You should interrupt CPR only when absolutely necessary and for as short a period as possible. Since you will be using a defibrillator on patients in cardiac arrest, you need to understand some additional circumstances when you should interrupt CPR. If you are touching the patient when the AED is analyzing the rhythm, there can be interference from the electrical impulses of your heart and from movement of the patient’s muscles. This can fool the AED’s computer into believing there is a shockable rhythm when there really isn’t one or vice versa.

It is also true that if a shock is delivered when you are touching the patient, the shock can be transmitted to you. Although this shock is not likely to cause you serious harm, you could be injured.

For these reasons, no one should ventilate, do chest compressions, or in any way touch the patient when the rhythm is being analyzed or a shock is being delivered.

Defibrillation is more effective than CPR in restoring a patient’s pulse, so briefly stopping CPR to allow for rhythm analysis and defibrillation is actually better for the patient.

Resume CPR immediately after delivering a shock.

Assessing and Managing a Cardiac Arrest Patient

1. If the patient appears lifeless, do a quick scan for breathing.

Obtain a quick history of events from family or bystanders.

2. Verify the absence of a spontaneous pulse. Check for no longer than 10 seconds.

3. Provide CPR while another EMT sets up the AED. 4. Turn on the AED power

Sa pinakamaagang panahon, tumawag na agad ng makakapagbigay ng Advanced Life Support bago ka pa man magbigay ng CPR at AED shocks sa isang pasyente na inatake sa puso.

PRINCIPLES OF EMT CLINICAL PRACTICE

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If the patient appears lifeless, do a quick scan for breathing. Obtain a quick history of events from family or bystanders.

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NOTE:

Researchers have evaluated whether it is better in the case of an unwitnessed arrest to start CPR first or to shock first. Although early studies suggested a brief period of CPR might increase survival, further evaluation has found that this provides little or no difference in outcomes. Some EMS systems stress CPR before defibrillation for unwitnessed arrests, whereas others have a second provider perform CPR only until an AED is available. For the sake of simplicity and ease of learning, this text follows the latter approach, though either is acceptable.

Follow your local protocols.

• As an EMT, you cannot diagnose heart ailments or causes of cardiac arrest. You must initiate CPR and defibrillation as rapidly as possible and. if defibrillation is not successful in restoring heart function, continue CPR to prevent biological death until the patient’s care can be taken over at a medical facility or by those with advanced skills.

• The proper dose of electricity for the shock depends on the type of unit you are using. For monophasic units the dose should be 360 joules (J). The ideal dose using a biphasic defibrillator is the dose at which the device has been shown to be effective in terminating VF. Biphasic defibrillators use energy levels between 120 to 200J. depending on the device.

CARDIAC ARREST TREATMENT SEQUENCE WITH AUTOMATED EXTERNAL DEFIBRILLATOR Verify arrest: unresponsive, apneic, and pulseless.

Have partner start CPR. Turn AED on.

Apply AED and clear patient.

Press analyse button.

Shock indicated (SI)

No shock indicated (NSI)

• Delivers 1 shock if AED gives SI message.

• If patient does not wake up, perform 2 minutes (5 cycles) of CPR. • Press analyse button.

• If SI, deliver 1 more shock if AED gives SI message.

• After 3 shocks, prepare for transport. Follow local protocols for additional shocks.

• Perform CPR for 2 minutes (5 cycles).

• Press analyse button.

• No shock indicated (NSI).

• Perform 2 minutes (5 cycles) of CPR.

Check pulse. If none, do CPR and Transfort.

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NOTE: Whenever a no shock indicated (NSI) message appears, begin 2 minutes (5 cycles) of CPR. If the patient regains a pulse, check breathing. Ventilate with highconcentration oxygen, or give oxygen by non rebreather mask as needed.

If you initially shock the patient and then receive an NSI message before giving six shocks, follow the steps in the right hand column.

If you initially receive an NSI message and then on a subsequent analysis receive a shock indicated (SI) message, follow the step in the left-hand column.

Occasionally you may need to shift back and forth between the two columns.

If this happens, follow the steps until one of the indications for transport (described bellow) occurs: • You have administered 3 shocks.

• You have received 3 consecutive NSI message (separated by 2 minutes of CPR).

• The patient regains a pulse.

If you shock the patient out of cardiac arrest and he arrests again, start the sequence of shocks from the beginning.

You should do no more than three cycles of analyze, shock/no shock advised, and CPR before beginning transport. Your local protocols may recommend initiating transport earlier in the sequence.

PATIENT ASSESSMENT Cardiac Arrest As with all calls, you should protect yourself from infectious diseases by using personal protective equipment and taking standard precautions. This is especially important in the case of a cardiac arrest where blood and other body fluids are commonly found. Patient assessment includes the following:

NOTE: In most patients you will encounter, the sequence of steps for patient assessment and treatment is A-B-C (airway, breathing, circulation).

However, for patients in cardiac arrest, the sequence of treatment will actually be C-A-B (circulation/compression, airway, breathing.)

PATIENT CARE Cardiac Arrest steps 1. Begin or resume high-quality CPR 2. Apply the AED in the following manner • If the patient is an adult (defined by the American Heart Association as reaching puberty or older), analyze and defib if shock is indicated • If the patient is a child or infant (defined as up to puberty), analyze and defib using an AED designed to provide shocks to children and infants If such an AED is not available, apply an ordinary AED In infants, you may need to apply one pad to the chest and the other to the back to prevent the pads from touching each other.

• Perform the primary assessment. If a bystander is doing CPR when you arrive, have the bystander stop. Spend no more than 10 seconds to verify pulselessness (no carotid pulse), apnea (no breathing) or agonal breathing (irregular gasping breaths), and absence of other signs of life (e.g. movement). Look for external blood loss.

To determine whether a patient be a candidate for immediate CPR. you must rapidly evaluate the patient as you approach, looking for any signs of life: responsiveness or movement of the chest that might indicate the presence of breathing.

If the patient has signs of life, you perform the head-tilt or jaw-thrust (airway) maneuver and check for respiration (breathing) and a pulse (circulation)—that is. A-B-C sequence. But if the patient appears to be lifeless (is unconscious, not moving and not breathing or has gasping breathing, and is pulseless), the first intervention you will perform is chest compressions followed by opening the airway and providing breathing— that is, C-A-B sequence.

In short, you should do what is best for the patient—A-B-C or C-A-B— based on what you find in your assessment.

• Resume CPR immediately, gather a history, and perform a physical exam. Inquire about onset, trauma, and signs and symptoms that were present before the patient collapsed. Get a past medical history if you can. However, do not let history gathering interfere with or slow down defibrillation or chest compressions.

• Bare the patient’s chest and. if necessary, quickly shave the area where the pads will be placed if the patient has a lot of chest hair.

• Turn on the AED. • Attach the monitoring/defibrillation electrode pads to the cables and then to the patient according to the instructions on the pads (upper right chest and lower left ribs). Many of these pads come already attached to the cable. It is helpful to remember “white to right and red to ribs.”

• Once the electrode pads are properly attached to the patient, advise all rescuers: “Stop CPR. We are analyzing.” The AED will search for ventricular fibrillation and if found, automatically charge the unit. Once fully charged, it will advise the EMT to clear the patient and deliver the shock to the patient. If the AED does not find a shockable ECG rhythm. it will advise the EMT that no shock is indicated and to resume CPR immediately.

• If the AED advises to deliver a shock, the EMT should ensure no one is touching the patient and then deliver a single shock.

Kung nadatnan mo na ang pasyente na may nakakabit na dito na AED, kailangan mong alamin kung ano na ang ginawa ng taong gumagamit ng AED. Kung sa tingin mo ay tama ang pagsusuri at pagbibigay ng shock ng taong may AED, hayaan mo na lamang siya na ituloy ito. Kung mali naman ang ginagawa nito, ituro mo ang tama o ikaw na ang gumawa para mas mapabuti ang lagay ng pasyente.

Ang kapakapanan ng pasyente ang pangunahing pakay mo sa pagpunta doon. Magtulung-tulong ang lahat para maisalba ang pasyente sa kamatayan.

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NOTE: As stated earlier, about half of all patient in cardiac arrest have “Analayze” button, the AED will give a “No Shock” message. In other cases, the AED will provide a “Deliver Shock” message and then after one or more shocks are delivered, give a “No Shock” message on a subsequent try. When the AED gives a “No Shock” message, it may be a very bad news -- the patient has a non-shockable heart rhythm and cannot be helped by the defibrillator. Or if may be very good news—the electrical rhythm of the patient’s heart has responded successfully to earlier shocks. In the latter case, even though the heart ‘s electrical activity has recovered, another stint of CPR may be required to get enough oxygen into the muscle cells of the heart to start it beating again.

Inside/Outside When the heart stops suddenly, oxygenated blood is present not only in the circulatory system but also in the brain and the muscles that control respiration—in particular, the intercostal muscles and the diaphragm. Since there is still some oxygen in the medulla, it is able to send occasional impulses through the nervous system to stimulate the respiratory muscles. As the patient inhales, the pressure in the thorax decreases. This encourages more blood to return to the heart. When the patient exhales, the pressure in the thorax increases. This promotes the movement of blood into the coronary arteries. Once the heart and arteries have oneway valves to push blood in one direction, it also increases blood flow to the aorta, carotid arteries, and the brain. This small amount of oxygen may actually allow the medulla to continue to send out some impulses to the respiratory muscles again, leading to a cycle in which the body attempts to resuscitate itself.

Unfortunately, this cannot go on forever. The amount of oxygen delivered to the medulla decreases with time, leading to a decrease in the number of breaths and then a downward, ending in death unless someone intervenes to improve perfusion (through CPR) and restart the heart’s electrical rhythm (through defibrillation). The word agonal refers to something that occurs just before death, so these respirations are traditionally referred to as agonal respirations.

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• Immediately begin CPR after delivering the shock. Sometimes a defibrillation will be immediately successful in generating the return of spontaneous circulation (ROSC), and the patient may wake right up. In most cases of a successful defibrillation, the patient may no longer be in VF but is still in cardiac arrest (most likely a period of non-perfusing rhythm) and needs CPR compressions to “keep the pump primed and circulation flowing’ • Reassess the patient—after providing 2 minutes or 5 cycles of CPR. reassess the patient (if the patient is waking up. check the pulse; if not waking up. repeat steps 6 to 8)

Outside When someone suddenly goes into cardiac arrest and collapses in front of a witness, up to half the time the patient may exhibit irregular, gasping breaths (agonal respirations) that do not look normal, but can still be confusing. These are the body’s attempts to prevent death, but they will last at most a few minutes, usually less. They are usually less frequent than normal respirations (even just a couple of times a minute in some cases) and more sudden and dramatic, not smooth and natural like normal breaths, although sometimes they are very brief and weak. Patients who exhibit agonal respirations have a high probability of survival when resuscitative measures (CPR. defibrillation) are provided, probably because agonal respirations are more often associated with shockable rhythms. In addition, they are an indication of the presence of oxygen in key areas like the heart and brain.

When you encounter a patient who exhibits agonal respirations, you should not let these respirations confuse you into thinking that the patient is breathing and therefore does not require CPR and defibrillation. If you don’t feel a pulse (or you are not sure you feel a pulse), perform chest compressions.

It is these patients, who have just gone into cardiac arrest, that have the greatest chance of survival with immediate highquality chest compressions and rapid defibrillation.

An even more confusing situation may occur during your resuscitation efforts. You may be compressing the chest when the patient suddenly takes a spontaneous, gasping breath.

If this happens, check the patient. Unless you are sure you feel a pulse, resume compressions. Take this as a good sign, however: You are providing enough oxygen to the brain, heart, and muscles for some impulses to get through to the respiratory muscles.

If the patient wakes or begins to move, get a set of baseline vital signs, ensure high-concentration oxygen administration, and prepare to transport the patient to the most appropriate ED. If an ALS unit will be arriving shortly, consider waiting for them or otherwise try to arrange for an “intercept” somewhere between the scene and the ED Research has shown that CPR performed while moving and/or transporting a patient is not of the best quality.

Whenever providing CPR. it is essential to remember: 1. Compressions must not be interrupted for any longer than 10 seconds e.g. reassessment, pulse checks, or placement of advanced airways).

2. Compressions should be at least 2 inches deep for an adult and at least onethird the depth of the chest for infants and children (about 2 inches for children and 1/2 inch for infants; with full chest recoil).

3. The rate should be at least 100-120 per minute, and 4. Personnel should rotate through the position of compressor to prevent rescuer fatigue.

Kung makakita ka ng “No Shock” na mensahe sa AED at nasuri mo na may pulso ang pasyente, pakiramdaman mabuti kung humihinga ito. Kung sapat ang paghinga, bigyan ito ng oxygen sa pamamagitan ng nonrebreather mask at ibiyahe na. Kung hindi naman sapat ang paghinga, bigyan ito ng artificial ventilation gamit ang high-concentrated oxygen sabay ibiyahe.

If the patient does not have return of spontaneous circulation after three shocks or two consecutive analyses without a shock, prepare to transport the patient to the most appropriate emergency hospital.

SPECIAL CONSIDERATIONS FOR AED USE General Principles Coordination with ALS Personnel

The following are general principles that apply to the use of an AED: • One EMT operates the defibrillator, while another does CPR. This prevents the EMT special considerations in who is operating the defibrillator from being distracted.

• Remember that CPR must include high-quality compressions.

• Defibrillation comes first. Do not hook up oxygen or do anything that delays analysis of the rhythm or defibrillation.

• You must be familiar with the particular model of AED used in your area.

• All contact with the patient must be avoided during analysis of the rhythm.

• Stale “Clear!” and be sure everyone is clear of the patient before delivering every shock.

• No defibrillator is capable of working without properly functioning batteries. Check the batteries at the beginning of your shift and carry a spare.

• If you have delivered three shocks (a rare occurrence) and you have no ALS backup, prepare the patient for transport. You may deliver additional shocks at the scene or en route if local medical direction approves.

• An AED cannot analyze a rhythm accurately in a moving emergency vehicle. You must completely stop the vehicle in order to analyze the rhythm if more shocks are ordered.

• Pulse checks should not occur during rhythm analysis.

You do not need to have an advanced life support (ALS) team at the scene in order to use an AED. However, the sooner the patient receives advanced cardiovascular life support (ACLS), the greater the patient’s chance of survival. If you have an ALS team available, notify them of the arrest as soon as possible (preferably before you even arrive on scene). Your Medical Director-approved local protocols should make whether you postpone transport and wait for the ALS team at the scene or start transport and rendezvous with them. Your actions may depend on the location of the arrest and the estimated time of arrival of the ALS team.

If the ALS team arrives before you have finished the first shock, they should allow you to complete the shock. They should then institute the advanced care that they can give. The ALS team may allow you to defibrillate later, but that will be their decision.

Since they are the most highly trained providers at the scene, the ALS team is responsible for the patient’s overall care.

Walang defibrillator na aandar kung walang baterya.

Tiyakin mo na may baterya ang AED na dala ng iyong team sa inyong ambulansya bago ang inyong shift. At tiyakin na meron kang reserbang baterya na pamalit sakaling humina na ang bateryang nakakabit sa AED.

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Coordination with Others Who Defibrillate Before You Arrive Emergency Medical Responders, police officers, security officers, and others may defibrillate the patient before you arrive. If this happens, you should let the operator of the AED complete the shock before you take over the care of the patient. After the shock is delivered, or a “No shock” message is received, work with the operator to bring about an orderly transfer of care.

In some areas, you may need to take the first AED to the hospital with the patient so that data can be retrieved from the machine. Your protocols should address this.

They also should tell you whether or not to switch from the first AED to your own.

Post-Resuscitation Care After you have run through the AED protocol, the patient will be in one of three conditions: 1. The patient has a pulse. In this case, you will need to keep a close eye on his airway and be aggressive in keeping it open. Keep the defibrillator on the pattern during transportation in case the patient goes back into arrest. En route, assess the patient based on what he tells you is bothering him. and reassess frequently, approximately every 5 minutes.

2. If the patient has no pulse, the AED w ill have given you a “No shock indicated” message, or 3. The AED may be prompting you to analyze the rhythm because it “thinks” there is a shockable rhythm. In any case, you will need to resume CPR. You will not perform further defibrillation once you have completed the initial shocks of the AED protocol unless the patient has recovered a pulse and then, later, goes back into cardiac arrest.

Part of your post-cardiac arrest care is to ensure adequate ventilation and oxygenation, but do not hyperventilate the patient. Ventilating a patient too many times a minute has very bad effects and can significantly decrease the chance of neurologically intact survival.

If your system provides therapeutic hypothermia after cardiac arrest, start the procedure or call for personnel who can.

For all of these patients, you will need to use the techniques of lifting and moving that you learned in “Lifting and Moving Patients.” You will also need to consider how and where to meet ALS personnel (if available).

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Patients Who Go Back into Cardiac Arrest A patient who has been resuscitated from cardiac arrest is at high risk of going back into arrest. This change may be difficult to detect since most patients who have just been resuscitated are unconscious and many of them will need assisted ventilation.

Since you are breathing for the patient. you may not notice that he no longer has a pulse. This is why, on unconscious patients who have recovered a pulse, you should check the pulse frequently (approximately every 30 seconds).

The AED may alert you that it “thinks” the patient has a shockable rhythm. If you get such a prompt from the defibrillator, check for a pulse immediately.

If you find that there is no pulse, follow these steps: 1. If you are en route, stop the vehicle.

2. Have someone else start CPR. if the AED is not immediately ready.

3. Analyze the rhythm.

4. Deliver a shock if indicated.

5. Continue with two shocks separated by 2 minutes (5 cycles) of CPR or as your local protocol directs.

Witnessed Arrests in the Ambulance Occasionally, you will be transporting a conscious patient with chest pain who becomes unconscious, pulseless, and apneic (not breathing). Although there are no guarantees, you have a very good chance of getting this patient back because you can defibrillate very shortly after the patient goes into a shockable rhythm. If this happens. stop the vehicle and treat him like any other patient in cardiac arrest.

Single Rescuer with an AED Some EMTs will be alone or have no one else nearby who can do CPR when they reach the patient. If this happens, the sequence of steps to take changes slightly. If no one else is available to perform CPR, apply the AED and defibrillate immediately. Once you have delivered a shock or received a “No shock indicated” message from the device, begin chest compressions and then ventilations. After about 2 minutes of CPR, check the rhythm again and shock as needed. Resume CPR for another 2 minutes and check the rhythm one more time. If you are still alone, continue in this fashion as your protocol directs until advanced help or transport arrives.

Contraindications The only contraindication to using a defibrillator is if the pads won’t fit on the patient without touching each other. There are patients for whom defibrillation will not be the best or only remedy, however. An example is trauma. If a patient has a serious traumatic injury and is in cardiac arrest (unless the arrest preceded the trauma), this is most likely caused by severe blood loss or damage to one or more vital organs. Even if the patient were defibrillated, chances of success are unlikely. Also, you should spend as little time as possible at the scene of a serious traumatic injury because the patient requires immediate transport to a facility where surgery can he performed.

Another case where defibrillation may not always be effective is hypothermia (very low body temperature). Patients who are severely hypothermic are usually warmed in a controlled setting before defibrillation is performed. Some systems recommend shocks in the event of cardiac arrest. If this does not work. The patient should be transported immediately.

Do not defibrillate a soaking-wet patient. Water is a very good conductor of electricity, so either dry the patient’s chest or move hint mil of the net environment (bring him inside, away from the rain, for example).

Do not defibrillate the patient if he is touching anything metallic that other people are touching. Metal is also a very good conductor of electricity.

This means that you must be careful if the patient is on a metal floor or deck, and you must make sure no one is touching the stretcher when you deliver a shock. It is also a good idea to make sure no one is touching anything, including a bag-valve mask, that is in contact with the patient.

If you see a nitroglycerin patch on the patient’s chest, remove it carefully before defibrillating. The plastic in the patch (not the nitroglycerin) may explode from the rapid melting that a defibrillatory shock can cause. This problem has been reported only when the patch is on the chest. Be sure to wear gloves when you remove the patch, as it is designed to release nitroglycerin through the skin, and it will not discriminate between the patient ‘s skin and yours. One thing you don’t need at a cardiac arrest is a headache from nitroglycerin.

Be absolutely sure that before every shock you say “Clear! and look from the patient’s head to his toes to ensure no one is touching the patient or any conductive material that the patient is touching. *** Be alert to safety hazards when using an AED. Do not defibrillate a patient who is wet or in contact with metal. Before defibrillation, remove a nitroglycerin patch if it is on the patient’s chest. Do not defibrillate until everyone is clear of the patient.

Ask your instructor or refer to your local DO NOT DEFIbRIllATE IF: protocols for guidelines for defibrillating patients who • Anyone is touching patient (be have experienced trauma or sure everyone is clear). arc severely hypothermic.

• Patient is wearing nitroglycerin As new technology and patch (Remove patch). information become available, • Patient is wet or patient is lying in your EMS system will keep water (Dry the patient). you advised of these updates • Patient is touching metal (move may alter future protocols for away from metal).

AED use.

PEDIATRIC NOTE Unlike adults, infants have healthy hearts and go into shockable rhythms less often Cardiac arrest in infants is more often caused by respiratory problems like foreign body airway obstruction or drowning For this reason, aggressive airway management and artificial ventilation with chest compressions are the best way to resuscitate these patients. AEDs are now on the market that can be adapted to pediatric use in infants and children through reducing the energy delivered and attaching smaller pads designed for then chests (smaller pads and smaller shocks) If your service has such on AED. you should follow the protocol for its use. If an adultsized AED ts the only one available and the pads fit on the patient’s chest without touching each other, it is better to use the adult AED on the child or infant than to continue CPR without using it.

Ang pagbibigay ng defibrillation ay paggamit ng kuryente para mapatibok uli ang puso ng pasyente.

Maging maingat sa pagsasagawa nito. Puwede kang makuryente at masaktan kung mali ang paraan ng iyong paggamit ng AED. Tiyakin na hindi basa ang pasyente at ang lugar kung saan ka gagamit ng AED. Tiyakin din na hindi bakal ang hinihigaan ng pasyente.

Matinding conductor ng kuryente ang tubig at bakal.

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Advantages of Automated External Defibrillation Until 30 years ago, it was unthinkable for EMTs to defibrillate patients in cardiac arrest.

Now. EMTs are expected to be trained and equipped to perform this potentially life-saving intervention. The biggest reason this situation has changed is the improvement in technology that allows defibrillators to quickly and accurately determine whether a patient’s rhythm is shockable.

This means that initial training and continuing education are much easier and simpler than that required for manual defibrillation in which the operator has to be able to read and analyze the heart rhythms that the AED does automatically. This is especially true in areas where EMTs see few cardiac arrests, such as in rural areas. Automated defibrillation is actually easier to learn and remember than CPR. However, this does not mean that EMTs are “well programmed robots.” You still must carefully perform a primary assessment to ensure that the patient is in cardiac arrest. You must memorize the treatment sequence, and you must always act with the safety of the patient and others in mind.

Automation also requires that the operator defibrillate through adhesive pads instead of paddles. This is safer and allows for more accurate and consistent electrode placement.

Since the operator does not have to hold paddles on the patient’s chest, there is almost no chance of “arcing” the passage of electrical current outside the chest from too little paddle pressure.

Certainly, the EMT’s level of anxiety is lower when he can push a button to deliver a shock instead of holding charged paddles on a patient’s chest.

Some AEDs may allow for monitoring of the rhythm of patients who are not in cardiac arrest.

This can be confusing for the CMT, since he is not trained in rhythm recognition and cannot treat nonshockable rhythms. A rhythm screen can be very distracting and take attention away from the patient. If you monitor patients with chest pain or difficulty breathing, make sure that this is allowed by your Medical Director.

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CARDIAC EMERGENCIES

Implants and Surgeries With the rapidly expanding medical technology available, the EMT may be presented with patients who have undergone surgeries or had special electronic devices implanted in the body. The ABC’s, including CPR and appropriate oxygen delivery, will not change because of prior surgery or conditions. Defibrillation can be performed on such a patient, although the positioning of defibrillation pads on the patient’s chest may need to be adjusted to avoid contact with an implanted device. Some of the devices and surgeries you may observe in the field include the following:

• Cardiac pacemaker. When the heart’s natural pacemaker does

not function properly, an artificial pacemaker can be surgically implanted to perform the same function. This pacemaker helps the heart heat in a normal, coordinated fashion. It is often placed below one of the clavicles, is visible as a small lump, and can be palpated. If you notice a lump under a clavicle, do not put a defibrillation pad over it. Try to put the pad at least several inches away while staying in the general area where you want the pad.

Occasionally pacemakers malfunction. Although this situation is rare, it is life threatening when it occurs. A malfunctioning pacemaker usually results in a slow or irregular pulse. The patient may have signs of shock due to the fact that the heart is not beating properly. Remember that care for patients with implanted pacemakers and signs of a cardiac emergency are the same as for those without a pacemaker. You should arrange for an ALS intercept and transport the patient immediately.

• Implanted defibrillator. Cardiologists are sometimes

able to identify patients who are at high risk of going into ventricular fibrillation. They sometimes receive a miniature defibrillator surgically implanted in the chest or abdomen.

When the patient develops a lethal cardiac rhythm, the implanted defibrillator detects it and shocks the patient.

Often an implanted defibrillator is actually a defibrillator and pacemaker. The number of patients receiving these devices will probably increase as it becomes easier to determine who is at risk of going into ventricular fibrillation. Since the implanted defibrillator is directly attached to the heart, low energy levels are needed for each shock. Many implanted defibrillators are also pacemaker functions. T he presence of the implanted defibrillator should not pose a threat to the EMT. Emergency care, CPR, and defibrillation for this patient are the same as for other cardiac patients.

• Cardiac bypass surgery. The coronary artery bypass has become

a relatively common procedure in cardiac surgery. A blood vessel from another part of the body is surgically implanted to bypass an occluded coronary artery. This helps restore blood flow to a section of the myocardium. Should a patient with a suspected myocardial infraction tell you that he has had bypass surgery, or if you observe a midline surgical scar on the chest of an unconscious patient, provide the same emergency care, including CPR and defibrillation, as for any other patient.

Quality Improvement There are many ways you can evaluate and improve your ability to resuscitate patients in cardiac arrest.

These methods should be part of your service’s quality improvement (QI) program. The defibrillation part of your (QI) program involves a number of things, including medical direction, initial training, maintenance of skills, case review, trend analysis, and strengthening the links in the chain of survival. Every participant in the EMS system has a role to play in QI, whether it is the patient who comes back to thank you, the physician who praises you for a

job well done, the nurse who follows upon the patient’s in-hospital course, or the EMT who uses the defibrillator and then documents the call.

An important part of making sure an AED is ready when you need it is to maintain it in accordance with the manufacturer’s recommendations. This includes checking the AED at the beginning of each shift. You should confirm that the battery in the AED has been charged if necessary and that monitoring-defibrillation pads are present that have not passed their expiration date.

Mechanical CPR Devices Some EMS agencies have chosen to utilize mechanical CPR compressor devices to assist the EMTs with providing highquality compressions. Realizing how important high-quality compressions are to the success of cardiac arrest resuscitation and that the mechanical devices can provide excellent compressions, it is important that a system be in place to apply the device early in the arrest with only a minimum interruption in the CPR (maximum of 10 seconds). Two devices are the Thumper and the Auto-Pulse. The following text shows how the devices would be worked into a typical cardiac arrest situation.

Using the Thumper

Using the Auto-Pulse™

• Take standard precaution.

• Ensure CPR is in progress and effective.

• Attach the thumper base plate to a long backboard.

• Stop CPR to slide the long backboard under the patient.

• Restart CPR and attach shoulder straps to the patient.

• Slide the Thumper’ piston plate into position on the base plate (away from the chest).

• Stop CPR and quickly pivot the piston arm into place, measuring ante-rior/posterior and middle sternum placement.

• Slowly adjust the depth of compression to the appropriate diagram.

• Adjust ventilations.

• Turn off the compressions temporarily (or pulse checks and defibrillation.

• Upon termination of arrest or return of spontaneous circulation, power down the unit.

• Take Standard Precautions.

• Ensure CPR is in progress and effective.

• Align the patient on the Auto-Pulse platform.

• Close the chest band over the patient’s chest.

• Press start (Auto-Pulse is designed to do the compressions automatically).

• Provide bag-mask ventilation at a rate of two ventilations for every 30 compressions.

Each ventilation should be given over 1 second to provide visible chest rise.

• If an advanced airway is in place there are no longer cycles of compressions to ventilations The compression rate is a continuous 100/min. and the ventilation rate is 8 to 10/min.

• After 2 minutes of CPR. reassess for pulse and/or shockable rhythm.

Tiyakin na tuluy-tuloy ang pagbomba sa dibdib ng pasyente. Kung matitigil man ito, tiyakin na hindi lalampas sa 10 segundo.

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NEXT to the stethoscope, the electrocardiogram (ECG) is the oldest and most enduring tool of the heart doctors. And as an EMT, you serve as an emergency heart doctor in the absence of one.

A basic knowledge of the ECG will enhance your understanding of how the heart works and how it is diagnosed.

This chapter is very technical and may require you to brush up on your anatomy and physiology knowledge, particularly on the topif of the circulation system.

You will deal with the heart rate, the heart rhythm, the cardiac axis, the various waves recorded by the ECG, and heart blocks. You will also be taught how to use an ECG caliper. Knowing all these will allow you to make sense of the ECG reading and diagnose your patient.

But interpreting the ECG reading is just half of the challenge. The first challenge really is how to properly use the ECG on your patient.

This chapter will teach you that, too. You will know about the leads that you will attach onto your patient’s limbs, and the correct way to attach them.

Mastering the ECG will allow you to better help your patient, assuring them that the machine -- although electronic in nature -- will not in anyway harm them but only measure their heart and tell if the heart is well.

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DAY

14

Basic ECG Reading Review of Circulatory System The Electrocardiogram ECG Interpretations

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1 large box = 5 small boxes = 5mm = 0.20 sec.

Day 14

5 large boxes 25 small boxesPRACTICE = 1 second PRINCIPLES OF=EMT CLINICAL

BASIC ECG READING

30 large boxes = 150 small boxes = 6 seconds

Normal Components of the ECG Waveform INTRODUCTION

REVIEW OF THE CARDIAC ANATOMY

LEARNING OBJECTIVES

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

The Cardiovascular System

• To have an understanding of the fundamentals of cardiac monitoring and dysrhythmia interpretation.

• Explain the physiology of cardiac conduction.

• Demonstrate how to read an ECG strip.

• Identify the normal components of the ECG waveform.

• Demonstrate correct placement of electrodes and lead selection.

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1. Blood Vessels—The Systematic Circulation 2. The Heart—The Blood Supply to the Heart 3. The Coronary Circulation 4. Cardiac Properties and Effects: Inotropy, Chronotropy, and Dromotropy Coronary and Systemic Blood Flow 5. Electrophysiology of the Myocardium • • • •

Action Potential The Refractory Period Pacemaker Cells Control of the Heart Rate

NOTE: Most of the contents of this chapter was based on the book “Emergency Care” by Daniel Limmer and Michael O’Keefe. Used with permission from Pearson Education, the publisher of the book.

DAY 14 The Conduction System of the Heart

The Conduction System of the Heart CONDUCTION SYSTEM

Components of the Conduction System • • • •

The Sinus Node The Atrioventricular Node The Bundle Branches The Purkinje Network

ABILITY TO INITIATE AN ELECTRICAL IMPULSE SINO-ATRIAL NODE

60-100

ATRIO-VENTRICULAR NODE

40-60

BUNDLE OF HIS

20-40

PURKINJE FIBERS

15-40

Components of the Conduction System

Review of Circulatory System Anatomy and Physiology  The Sinus Node Structure/function 1. Atrium

• Right - receives blood from the veins of the body and the heart and pumps oxygen-poor blood to the right ventricle.

• Left - receives blood from the pulmonary veins (lungs) and pumps oxy-gen-rich blood to left ventricle.

 The Atrioventricular Node Blood Vessels  The Bundle Branches

1. Arteries - carry blood away  The Purkinje Network 2.

3.

2. Ventricle

• Right - pumps blood to the lungs.

• Left - pumps blood to the body.

3. Valves prevent backflow of blood

4.

5.

from the heart to the rest of the body.

Arterioles - the smallest branches of an artery leading to the capillaries.

Capillaries - Tiny blood vessels that connect arterioles to venules.

• Found in all parts of the body • Allow for the exchange of nutrients and waste at the cellular level.

Venules - the smallest branches of the veins leading to the capillaries.

Veins - vessels that carry blood back to the heart.

Blood composition 1. Red blood cells - Give

2.

3.

4.

the blood its color. Carry oxygen to organs and Carry carbon dioxide away from organs.

White blood cells - part of the body’s defense against infections.

Plasma - fluid that carries the blood cells and nutrients.

Platelets - essential for the formation of blood clots

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BASIC ECG READING

Review of the Phases of Cardiac Action (Cardiac Cycle) The cardiac cycle refers to the sequence of mechanical and electrical events that repeats with every heartbeat. It includes the phase of relaxation (diastole) and the phase of contraction (systole). The human heart is a four-chambered organ. Thus there are atrial systole, atrial diastole, ventricular systole, and ventricular diastole.

The frequency of the cardiac cycle is described by the heart rate, which is typically expressed as beats per minute. Each cycle of the heart, from the point of view of the ventricles and the status of their valves, involves a minimum of four major stages: Inflow phase, isovolumetric contraction, outflow phase and isovolumetric relaxation.

The first and the fourth stages, together, constitute the “ventricular diastole” stage. This stage involves the movement of blood from the atria into the ventricles. Stages 2 and 3 involve the “ventricular systole” i.e. the movement of blood from the ventricles to the pulmonary artery (in the case of the right ventricle) and the aorta (in the case of the left ventricle).

Ventricular diastole begins when the ventricles start to relax. At this point, some blood of the previous cycle’s systole is still flowing out of the ventricles through the semilunar valves due to the inertia of the moving blood column, which overcomes the higher pressure in the aorta/pulmonary trunk with respect to the pressure in the ventricles. This short lasting phase, called protodiastole, ends with the closure of the semilunar valves, producing the second heart sound (S2).

Now that both the AV valves and the semilunar valves are closed, the ventricles are now closed chambers. Hence, this phase is known as isovolumetric relaxation phase. Then the atrioventricular (AV) valves (the mitral valve and the tricuspid valve) open, allowing blood to fill the ventricles. This ventricular inflow phase can be sub-divided into the first rapid filling phase as blood rushes in from the atria as a result of ventricular dilation; a phase of slow ventricular filling called diastasis, and the last rapid filling phase due to atrial contraction (systole).

As the ventricular systole begins, pressure within, the ventricle rises and the AV valve closes producing the first heart sound (S1). The semilunar valves remain closed. The contracting ventricles become closed chambers again and this phase is termed as isovolumetric contraction. As the name implies, there

is no change in volume, but intra-ventricular pressure rises.

The outflow phase, or the ventricular ejection, is when the intra-ventricular pressure has achieved a higher pressure than the blood in the aorta (or the pulmonary trunk), the corresponding semilunar valves open. The ejection phase begins.

Throughout the cardiac cycle, blood pressure increases and decreases. The cardiac cycle is coordinated by a series of electrical impulses that are produced by specialized pacemaker cells found within the sinoatrial node and the atrioventricular node. The cardiac muscle is composed of myocytes which initiate their own contraction without the help of external nerves. The duration of the cardiac cycle is the reciprocal of heart rate. Assuming a heart rate of 75 beats per minute, each cycle takes 0.8 seconds.

Origin and Spread of Excitation in the Heart The heart contains muscle cells (fibers) that produce and distribute excitation impulses (conducting system), as well as working myocardium, which responds to the excitation by contracting. Contrary to the situation in skeletal muscle, excitation originates within the organ (autorhythmicity or autonomy of the heart). Atrial and ventricular myocardium each consists functionally of a syncytium, i.e., the cells are not insulated from one another but connected through gap junctions. A stimulus that originates somewhere within the atria or ventricles thus always leads to complete contraction of both atria or of both ventricles, respectively (all-or-nothing contraction).

Normal excitation of the heart originates within the sinus node, the heart’s pacemaker. Excitation spreads from there through both atria to the atrioventricular node (AV node) and from there, via the His bundle and its two (Tawara) branches, reaches the Purkinje fibers, which transmit the excitation to the ventricular myocardium. Within 346

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the myocardium the excitation spreads from inside to outside What the first three processes have in common is (endocardium toward epicardium) and from apex toward that the threshold is reached later than before. All parts the base, a process that can be followed—even in the intact of the excitation/conduction system have the capacity organism— by means of the ECG. of spontaneous depolarization, but the sinus node plays The potential in the cells of the sinus node is a pacemaker the leading role in nor-mal cardiac excitation (sinus potential. It has no constant resting potential, but rises after rhythm is ca. 70–80 beats per minute). The reason for each repolarization. The most negative value of the latter is this is that the other parts of the conduction system called maximal diastolic potential ([MDP] ca. – 70 mV). It have a lower intrinsic frequency than the sinus node. rises steadily until the threshold potential ([TP] ca. – 40 mV) Excitation starting from the sinus node will thus is reached once more and an action potential (AP) is again arrive at more distal parts of the conducting system, triggered. before their spontaneous depolarization has reached Although the heart beats autonomously, adaptation of cardiac activity to changThe following changes in ionic conductance (g) of the the TP. However, if conduction of the sinus impulse plasma membrane and thus of ionic currents (I) cause these ing demands is mostlyis interrupted the intrinsic frequency of more distal effected through efferent cardiac nerves. The following ELECTROCARDIOGRAM (ECG) potentials: Beginning with the MDP, nonselective conductance parts of the conduction system take over and the heart qualities of cardiac activity can be modified by nerves: is increased and influx of cations into the cell leads to slow then beats in AV rhythm (40–60 beats per minute) or,  Rate of impulse formation of the pacemaker and thus of the heart beat depolarization (prepotential = PP). Once the TP has been in certain circumstances, at the even lower rate of the Graphic recording of the elec(chronotropism); reached, gCa now rises relatively rapidly, the potential rising so-called tertiary (ventricular) pacemakers (20–40 beats trical activity of the heart, It  Velocity of per minute). impulse conduction, especially in the AV node more steeply so that an increased influx of Ca2+ (ICa) produces depicts the electrical activity of the upstroke of the AP. While the potential overshoots (dromotropism); In contrast to the sinus and AV nodes with their the heart. The excitatory and to positive values, leading to an outward K+ flux IK, the  The force ofrelatively slowly rising AP, due largely to an influx of myocardial contraction at a given distension, i.e., the pacemaker cell is again repolarized to the MDP. Ca2+, there are in the working myocardium so-called electrical conduction system of (inotropism); heart’s contractility rapid, voltage-gated Na+ channels that at the beginning the heart is responsible for the  Excitability of the heart in the sense of changing its excitability threshEach AP in the sinus node normally results in a heart beat, of the AP briefly cause a high Na+ influx and therefore, contraction and relaxation of old (bathmotropism). compared with the pacemaker potential, a relatively rapid i.e., the impulse frequency of the pacemaker determines the the heart muscle. The electrical rise in the upstroke of the AP. The relatively long duration rate of the heart beat. The rate is lower if These changes in cardiac activity are caused by parasympathetic fibers of the currents generated by the (compared with skeletal muscle) of myocardial AP, giving • the rise of the slow depolarization becomes less steep, vagus nerve and by sympathetic fibers. Heart rate is increased by the activity of it the shape of a plateau, has an important function in • the TP becomes less negative, heart spread through the body sympathetic fibers to that it prevents circles of myocardial excitation (reentry). the sinus node (positive inotropic effect via "1-receptors) • the MDP becomes more negative so that spontaneous to the skin, where they can be and decreased by parasympathetic, muscarinic fibers (negative chronotropic This also holds true for very high and low heart rates, depolarization begins at a lower level, or sensed by appropriately placed effect). This is due to changes in the slow depolarization rise and altered MDP in because the duration of AP adapts to the heart rate.

• repolarization in an AP starts later or is slower. electrodes, amplified and the sinus node. viewed. ECG Provide information on the following: The Electrocardiogram (ECG)

UNIT 3 DAY 14

PRINCIPLES OF EMT CLINICAL PRACTICE

The Electrocardiogram (ECG)

 Orientation of the heart in

The ECG is a recording of potential differences the chest that are generated by the excitation within the heart. It  Conduction disturbances can provide information about the position of the heart and its rate and rhythm as well as the origin and spread  Electrical effects of medicaof the action potential, but not about the contraction tions and electrolytes and pumping action of the heart. The ECG potentials  Mass of cardia muscle originate at the border between excited and nonexcited parts of the myocardium. Non-excited or completely  Presence of ischemic damexcited myocardium does not produce any potentials age which are visible in the ECG. During the propagation of

the excitation front through the myocardium, manifold  Electrodes placed on the potentials occur, differing in size and direction. skin measure the direction of The limb and precordial leads of the ECG record the the electrical current distemporal course of the summated vectors, projected onto charged by the heart that the respective plane (in relation to the body) of the given then transformed into wave lead. A lead parallel to the summated vector shows the full the junction of the two other limb electrodes. These leads, too, deflection, while one at a right angle to it shows none. The The ECG is a recording of potential differences (in mV) that are generated by the forms lie in the frontal plane. The unipolar precordial leads V1–V6 Einthoven (or standard limb) leads I, II, and III are bipolar excitation within the heart.

It can provide information about the position of the  ECG records information (Wilson leads) lie approximately in the horizontal plane (of and lie in the frontal plane. For the unipolar Goldber-ger heart and its rate and rhythm as well as the origin and spread of the action poabout those wave forms (limb) leads, aVL, aVR, and aVF (a = augmented), one tential, but notthe upright body). They mainly record those vectors that are about the contraction and pumping action of the heart. The limb electrode (e.g., the left arm in aVL) is connected to from different angles (views) ECG potentials directed posteriorly. As the mean QRS vector mainly points originate at the border between excited and nonexcited parts of the myocardium. Nonexcited or completely excited (i.e., depolarized) myocardium does not produce any potentials which are visible in the ECG. During the LIFELINE PREHOSPITAL EMERGENCY CARE 347 potenpropagation of the excitation front through the myocardium, manifold tials occur, differing in size and direction.

The limb and precordial leads of the ECG record the temporal course of the summated vectors, projected onto the respective plane (in relation to the body) of

Day 14

ELECTROCARDIOGRAM (ECG) Graphic recording of the electrical activity of the heart, It depicts the electrical activity of the heart. The excitatory and electrical conduction system of the heart is responsible for the contraction and relaxation of the heart muscle. The electrical currents generated by the heart spread through the body to the skin, where they can be sensed by appropriately placed electrodes, amplified and viewed.

ECG provides information on the following: • Orientation of the heart in the chest • Conduction disturbances • Electrical effects of medications and electrolytes • Mass of cardia muscle • Presence of ischemic damage • Electrodes placed on the skin measure the direction of the electrical current discharged by the heart that then transformed into wave forms • ECG records information about those wave forms from different angles (views)

Mahalaga ang ECG para malaman kung normal ba ang kuryente sa puso. Oo, may kuryente sa puso at ito ang dahilan ng pagtibok nito.

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BASIC ECG READING

downward to the left and posteriorly, the thoracic cage is divided into a positive and a negative half by a plane which is vertical to this vector. As a result, the QRS vector is usually negative in V1–V3, positive in V5–V6.

An ECG tracing has waves, intervals, and segments (deflection upward +, downward –). The P wave (normally < 0.25mV, < 0.1 s) records depolarization of the two atria. Their repolarization is not visible, because it is submerged in the fol-lowing deflections. The Q wave (mV < 1⁄4 of R), the R and S waves (R + S > 0.6 mV) are together called the QRS complex (< 0.1 s), even when one of the components is missing. It records the depolarization of the ventricles; the T wave records their repolarization. Although the two processes are opposites, the T wave is normally in the same direction as that of the QRS complex (usually + in most leads), i.e., the sequence of the spread of excitation and of repolarization differs: the APs in the initially excited fibers (near the endocardium) last longer than those excited last (near the epicardium).

The PQ segment (fully depolarized atria) and the ST segment (fully depolarized ventricles) are approximately at the zero mV level (isoelectric line). The PQ interval

(< 0.2 s) is also called (atrioventricular) transmission time. The QT interval depends on heart rate. It is normally 0.35–0.40 seconds at 75 beats per minute (time taken for ventricular depolarization and repolarization).

The six frontal limb leads (standard and augmented) are included in the Cabrera circle. The simultaneous summated vector in the frontal plane, for example, the mean QRS vector, can be determined by using the Einthoven triangle or the Cabrera circle. When the spread of excitation is normal, its position corresponds approximately to the anatomic longitudinal axis of the heart (electrical axis of the heart). The potential of the mean QRS vector is calculated (taking the positivity and negativity of the deflections into account) from the height of the Q, R, and S deflections. The normal positional type of the electrical axis extends from + 90° to – 30° (for arrangement of degrees). Abnormal positional types are marked right axis deviation (> + 120°) , for example, in right ventricular hypertrophy, and marked left axis deviation (more negative than – 30°), for example, in left ventricular hypertrophy. Extensive myocardial infarcts can also change the electrical axis.

Abnormalities of Cardiac Rhythm

Disorders of rhythm (arrhythmias or dysrhythmias) are changes in the formation and/ or spread of excitation that result in a changed sequence of atrial or ventricular excitation or of atrioventricular transmission. They can affect rate, regularity, or site of action potential formation.

Action potential formation in the sinus node occurs at a rate of 60–100 per minute (usually 70–80 per minute at rest). During sleep and in trained athletes at rest and also in hypothyroidism, the rate can drop below 60 per minute (sinus bradycardia), while during physical exercise, excitement, fever, or hyperthyroidism it may rise to well above 100 per minute (sinus tachycardia). In both cases the rhythm is regular, while the rate varies in sinus arrhythmia. This arrhythmia is normal in juveniles and varies with respiration, the rate accelerating in inspiration, slowing in expiration.

Tachycardia of ectopic origin. Even when the stimulus formation in the sinus node is normal, abnormal ectopic excitations can start from a focus in an atrium (atrial), the AV node (nodal), or a ventricle (ventricular). High-frequency ectopic atrial depolarizations (sawtoothed base line instead of regular P waves in the ECG) cause atrial tachycardia, to which the human ventricles can respond to up to a rate of 200 per minute. At higher rates, only every second or third excitation may be transmitted, as the intervening impulses fall into the refractory period of the more distal conduction system, the conduction component with the longest AP being the determining factor. This is usually the Purkinje fibers, which act as frequency filters, because their long action potential stays refractory the longest, so that at a certain rate further transmission of the stimulus is blocked.

At higher rates of discharge of the atrial focus (up to 350 per minute = atrial flutter; up

to 500 per minute = atrial fibrillation), the action potential is transmitted only intermittently. Ventricular excitation is therefore completely irregular (absolutely arrhythmic).

Ventricular tachycardia is characterized by a rapid succession of ventricular depolarizations. It usually has its onset with an extrasystole (ES). Ventricular filling and ejection are reduced and ventricular fibrillation occur (high-frequency and uncoordinated twitchings of the myocardium). If no countermeasures are taken, this condition is just as fatal as cardiac arrest, because of the lack of blood flow.

Conduction disorders in the AV node (AV block) or His bundle can also cause arrhythmias. First degree (1°) AV block is characterized by an abnormally prolonged AV transmission (PQ interval > 0.2 s); second degree (2°) AV block by intermittent AV transmission (every second or third P wave);

and third degree (3°) AV block by completely blocked AV transmission. In the latter case the heart will temporarily stop (Adams–Stokes attack), but ventricular (tertiary) pacemakers then take over excitation of the ventricles (ventricular bradycardia with normal atrial rate). Partial or complete temporal independence of the QRS complexes from the P waves is the result. The heart (i.e., ventricular) rate will fall to 40–60 per minute if the AV node takes over as pacemaker, or to 20–40 per minute when a tertiary pacemaker (in the ventricle) initiates ventricular depolarization. This could be an indication for employing, if necessary implanting, an artificial (electronic) pacemaker. Complete bundle branch block (left or right bundle) causes marked QRS deformation in the ECG, because the affected part of the myocardium will have an abnormal pattern of depolarization via pathways from the healthy side.

Changes in cell potential Important prerequisites for normal excitation of both atrial and ventricular myocardium are: 1. a normal and stable level of the resting potential (– 80 to – 90 mV); 2. a steep upstroke (dV/dt = 200– 1000 V/s); and 3. an adequately long duration of the AP. These three properties are partly independent of one another. Thus the “rapid” Na+ channels cannot be activated if the resting potential is less negative than about – 55mV. This is caused mainly by a raised or markedly lowered extracellular concentration of K+, hypoxia, acidosis, or drugs such as digitalis. If there is no rapid Na+ current, the depolarization is dependent on the slow Ca2+ influx (L type Ca2+ channel; blockable by verapamil, diltiazem or nifedipine). The Ca2+ influx has an activation threshold of – 30 to – 40mV, and it now generates an AP of its own, whose shape resembles the pacemaker potential of the sinus node. Its rising gradient dV/ dt is only 1–10 V/s, the amplitude is lower, and the plateau has largely disappeared. (In addition, spontaneous depolarization may occur in certain conditions, i.e., it becomes a source of extrasystoles. Those APs that are produced by an influx of Ca2+ are amplified by norepinephrine and cell stretching.

They occur predominantly in damaged myocardium, in whose environment the concentrations of both norepinephrine and extracellular K+ are raised, and also in dilated atrial myocardium. Similar AP changes also occur if, for example, an ectopic stimulus or electric shock falls into the relative refractory period of the preceding AP. This phase of myocardial excitation is also called the vulnerable period. It is synchronous with the rising limb of the T wave in the ECG. Reentry in the myocardium. A decrease in dV/dt leads to slow propagation of excitation, and a shortening of the AP means a shorter refractory period. Both are important causes of reentry, i.e., of circular excitation. When the action potential spreads from the Purkinje fibers to the myocardium, excitation normally does not meet any

myocardial or Purkinje fibers that can be reactivated, because they are still refractory.

Reentry in the AV node. While complete AV block causes a bradycardia (see above), partial conduction abnormality in the AV node can lead to a tachycardia. Transmission of conduction within the AV node normally takes place along parallel pathways of relatively loose cells of the AV node that are connected with one another through only a few gap junctions. If, for example, because of hypoxia or scarring, the already relatively slow conduction in the AV node decreases even further. Reentry can only occur if excitation (also slowed) along another pathway can circumvent the block by retrograde transmission so that excitation can reenter proximal to the block.

In Wolff–Parkinson–White syndrome the circle of excitation has an anatomic basis, namely the existence of an accessory, rapidly conducting pathway (in addition to the normal, slower conducting pathway of AV node and His bundle) between right atrium and right ventricle. In normal sinus rhythm the excitation will reach parts of the right ventricular wall prematurely via the accessory pathway, shortening the PR interval and deforming the early part of the QRS complex.

Should an atrial extrasystole occur in such a case, negative P wave), excitation will first reach the right ventricle via the accessory pathway so early that parts of the myocardium are still refractory from the preceding normal action potential.

Most parts of the ventricles will be depolarized via the AV node and the bundle of this so that the QRS complex for the most part looks normal. Should, however, the normal spread of excitation (via AV node) reach those parts of the ventricle that have previously been refractory after early depolarization via the accessory pathway, they may in the meantime have regained their excitability. The result is that excitation is now conducted retrogradely via the accessory pathway to the atria, starting a circle of excitation that leads to the sudden onset of (paroxysmal) tachycardia, caused by excitation reentry from ventricle to atrium.

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349

Abnormalities of Potassium Balance

Day 14

UNIT 3 DAY 14

An abnormal potassium level is the result of a disorder of K+ balance or of its distribution between the intracellular and extracellular space. A decrease in K+ concentration reduces the conductance of the K+ channels, thus decreasing the hyperpolarizing effect of K+ on the membrane potential. This promotes the heterotopic automaticity of the heart that may even trigger ventricular fibrillation.

The reduction of K+ conductance is also responsible for delayed repolarization of the Purkinje fibers. Hypokalemia often produces a prominent U wave in the electrocardiogram (ECG). Conversely, hyperkalemia increases the K+ conductance, the action potential is shortened, and correspondingly also the ST segment in the ECG.

BASIC ECG READING

PRINCIPLES OF EMT CLINICALBalance PRACTICE Abnormalities of Potassium

UNIT 3 DAY 14 PRINCIPLES OF EMT CLINICAL PRACTICE

An abnormal potassium level is the result of a disorder of K+ balance or of its distribution between UNIT 3 Abnormalities of Magnesium Balance the intracellular and extracellular space. A decrease in DAY 14 K+ concentration reduces the conductance of the K+ The effects of Mg2+ deficiency are an increased neuromuscular excitability, hychannels, thus decreasing the hyperpolarizing effect perreflexia, and cramps. These cramps sometimes resemble those after damage toof K+ on the membrane potential. This promotes the the basal ganglia. Cardiovascular signs can be tachycardia and arrhythmias, even ventricular fibrillation, and a rise in blood pressure. These symptoms are Abnormalities of Magnesium Balance heterotopic automaticity of the heart that may even accentuated (if not in fact caused by) hypercalcemia that may occur as a result of a trigger ventricular fibrillation. The reduction of K+ decreased release of PTH (Mg2+ stimulates the release of PTH). Usually Mg2+ deficiency coexists with K+ deficiency so that the symptoms of hypokalemia are The effects of Mg2+ deficiency are an increased neuromuscular excitability, hyconductance is also responsible for delayed repolarization accentuated.

The effects of Mg2+ excess are impaired neuromuscular excitability perreflexia, and cramps. These cramps sometimes resemble those after damage of the Purkinje fibers. Hypokalemia often produces a (hyporeflexia) that may even lead to respiratory arrest, disorders of cardiac action to the basal ganglia. Cardiovascular signs can be tachycardia and arrhythmias, prominent U wave in the electrocardiogram (ECG). potential generation and propagation, vomiting, and constipation even ventricular fibrillation, and a rise in blood pressure. These symptoms are Conversely, hyperkalemia increases the K+ conductance, accentuated (if not in fact caused by) hypercalcemia that may occur as a result of a decreased release of PTH (Mg2+ stimulates the release of PTH). Usually Mg2+ the action potential is shortened, and correspondingly deficiency coexists with K+ deficiency so that the symptoms of hypokalemia are also the ST segment in the ECG. ² Limmer (Brady)

Abnormalities of Calcium Balance

³ Pollack, (AAOS) accentuated.

The effects of Mg2+ excess are impaired neuromuscular excitability ⁴ NHTSA (hyporeflexia) that may even lead to respiratory arrest, disorders of cardiac action potential generation and propagation, vomiting, and constipation

The clinically most significant effect of hypocalcemia is an increased excitability of muscles and nerves with the occurrence of involuntary muscle spasms (tetany) and paresthesias. The increased excitability is probably due to the lowered threshold of Na+ channels in hypocalcemia. In severe cases epileptic seizures may occur. Hypocalcemia triggers a lengthening of the action Abnormalities of Calcium Balance potential in the heart because of the delayed activation The clinically most significant effect of hypocalcemia is an increased excitability of the K+ channels, resulting in prolongation of the ST ofsegment and QT interval in the ECG. The effects of muscles and nerves with the occurrence of involuntary muscle spasms (tetany) and paresthesias. The increased excitability is probably due to the lowhypercalcemia, the ECG the ST segment is shortened in ered threshold of Na+ channels in hypocalcemia. In severe cases epileptic seiline with accelerated activation of the repolarizing K+ zures may occur. Hypocalcemia triggers a lengthening of the action potential in the heart because of the delayed activation of the K+ channels, resulting in pro- Abnormalities of Calcium Balance channels. Of great clinical significance in hypercalcemia longation of the ST segment and QT interval in the ECG. The effects of hypercalis the increased sensitivity of the heart to digitalis, as this cemia, the ECG the ST segment is shortened in line with accelerated activation of effect is normally mediated via an increased cytosolic the repolarizing K+ channels. Of great clinical significance in hypercalcemia is The clinically most significant effect of hypocalcemia is an increased excitability The effects of Mg2+ deficiency are an increased the increased sensitivity of the heart to digitalis, as this effect is normally medi- of muscles and nerves with the occurrence of involuntary muscle spasms Ca2+ concentration. (tetany) and paresthesias. The increased excitability is probably due to the lowneuromuscular excitability, hyperreflexia, and ated via an increased cytosolic Ca2+ concentration. eredcramps. These cramps sometimes resemble those threshold of Na+ channels in hypocalcemia. In severe cases epileptic seizures may occur. Hypocalcemia triggers a lengthening of the action potential in after damage to the basal ganglia. Cardiovascular the heart because of the delayed activation of the K+ channels, resulting in prosigns can be tachycardia and arrhythmias, longation of the ST segment and QT interval in the ECG. The effects of hypercalcemia, the ECG the ST segment is shortened in line with accelerated activation of even ventricular fibrillation, and a rise in blood the repolarizing K+ channels. Of great clinical significance in hypercalcemia is pressure. These symptoms are accentuated (if not the increased sensitivity of the heart to digitalis, as this effect is normally mediin fact caused by) hypercalcemia that may occur ated via an increased cytosolic Ca2+ concentration. as a result of a decreased release of PTH (Mg2+ stimulates the release of PTH). Usually Mg2+ “ deficiency coexists with K+ deficiency so that the symptoms of hypokalemia are accentuated. The effects of Mg2+ excess are impaired neuromuscular excitability (hyporeflexia) that may even lead to respiratory arrest, disorders of cardiac action potential generation and propagation, vomiting, and ² Limmer (Brady) ³ Pollack, (AAOS) constipation ⁴ NHTSA

Abnormalities of Magnesium Balance

350

LIFELINE

PREHOSPITAL EMERGENCY CARE ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

3. The Precordial Leads— V1, V2, V3, V4, V5, V6

UNIT 3 DAY 14

PRINCIPLES OF EMT CLINICAL PRACTICE

3 Types of Leads

PRINCIPLES OF EMT CLINICAL PRACTICE Fig. 1. The Standard Limb Leads— When setting up standard limb leads, you will place electrodes in positions commonly referred as EINTHOVEN’S TRIANGLE Fig. 2. Augmented Limb Leads—aVR, aVL, aVF Fig. 3. The Precordial Leads— V1, V2, V3, V4, V5, V6

Figure 1

EINTHOVEN’S TRIANGLE “

Figure 2 AUGMENTED LIMB LEADS

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

Figure 3

THE PRECORDIAL LEADS

LIFELINE ² Limmer (Brady)

³ Pollack, (AAOS) ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

351

L P I

C

N I R

Day 14

THE CALIPER 3 P

E P I L IT 4 A An ECG caliper (sometimes plural like UNIT C 3 N 1 scissors) is a tool that helps measure certain E U Y values. It usually has no measuring ability of its HDAY 14 A T own, but allows you to set its width and then D

PLES OF EMT CLINICAL PRACTICE

PER

se the

t lp lly s o s ns of i e h ua it it ga n f s t o se it a rtio u y re po it u s to ea nt UN PRINCIPLES OF EMT CLINICAL PRACTICE UN m nie r. ve pe DA DA a p R

O S E

PLES OF EMT CLINICAL PRACTICE

IPER

pl

An ECG caliper (sometimes plural like scissors) is a tool that helps measure certain values. It usually has no measuring abilAn ECG caliper (sometimes ity of its own, but allows you plural like scissors) is a tool that to set its width and then helps measure certain values. It measure it against a more con-venient portion measure it against a more conusually has no measuring abilof the ECG paper. venient portion of the ECG ity of its own, but allows you paper. to set its width and then measure it against a more convenient portion of the ECG paper.

Caliper

How to use the Caliper

UNIT 3 DAY 14

PRINCIPLES OF EMT CLINICAL PRA HOW TO READ AN ECG STRIP

Ca

th e th . e e s h f HOW TO READ AN ECG STRIP t o sur re m r e a a a d us o en me s tw h to to arm c e w th ea end the o t H on on in at tal i t u th n si r Po lipe yo re rizo ca idth su ho 1. w ake ctly M rfe pe

HOW TO READ AN ECG STRIP

thethe twoCaliper arms of use

the on each end of the ou intend to measure. urethethat arms n twothe arms of are the y on horizontal each end of the

you intend to measure. sure that the arms are y horizontal

1. Position the two arms of the caliper on each end of the width you intend to measure. Make sure that the arms are perfectly horizontal

u have positioned the arms, do not let them elative to each other). uld defeatpositioned the purpose ou have the garms, the calipers.

Find a do not let them nrelative the paper that other). it will to each to see the lines.

Keepould defeat the purpose wothe caliper arms on thea g calipers.

Find ertical level, place n the paper that it the will onKeepthe y of to the see caliper the lines. etwo ofcaliper a big armssquare. on the ber that level, each box is five vertical place the by muares). of theMultiply caliper this on the convert the number of de of a big square. uaresthat intoeach seconds. mber box is five

ECG RATE

ECG RATE ECG RATE

quares). Multiply this by convert the number of quares into seconds.

2. After you have positioned the caliper arms, do not let them move (relative to each other). This would defeat the purpose of using the calipers.

Find a place on the paper that it will “ be easy to see the lines. Keeping the two caliper arms on the same vertical level, place the left arm of the caliper on the left side of a big square. “ (remember that each box is five small squares). Multiply this by 0.04 to convert the number of small squares into seconds.

LIFELINE

PREHOSPITAL EMERGENCY CARE

of

yo t Af lipe 1 small = 0.04 1 large box = 5 small boxesbox = 5mm = 0.20seconds sec. ca o 2. m 5 large boxes = 25 small boxes = 1 second er

1 small box = 0.04 seconds

1 large box = 5 small boxes = 5mm

30 large boxes = 150 small boxes = 6 seconds

5 large boxes = 25 small boxes = 1 s

Normal Components of the ECG Waveform 30 large boxes = 150 small boxes = 1 small box = 0.04 seconds Normal Components ofsec.the“ECG 1 large box = 5 small boxes = 5mm = 0.20 5 large boxes = 25 small boxes = 1 second 30 large boxes = 150 small boxes = 6 seconds “

“ 352

r

e PRINCIPLES OF EMT CLINICAL lip PRACTICE e

Waveform

NIT NIT 3 3 AY AY 14

PRINCIPLES OF EMT EMTCLINICAL CLINICALPRACTICE PRACTICE PRINCIPLES OF Normal Components of the ECG Waveform

P WAVE WAVE ACTICEP WAVE

Description: Description: Description: • Represents electrical activity associated with original impulse from  the SA node and its passage thru the atria Represents from thethe SASA Represents electrical electrical activity activityassociated associatedwith withoriginal originalimpulse impulse from • Atrial depolarization and contraction of the atria node and its passage thru the atria node and its passage thru the atria • Concave and small; no notching or peaking.  Atrial depolarization and contraction of the atria  Atrial and contraction of the atria e depolarization  Concave and small; no notching or peaking. h t  Concave m and small; no notching or peaking. d

e ne th er). o PR t iti INTERVAL le oth ose sPR INTERVAL o a p ot h rp n u c e d a ill p in v ha , do to e the . F it w pou rms ve at ers at Kee he a lati efe alip th s. n t e r th e e (re d d c per line s o l u the pa e rm ce th . e ov wo g he e th er a pla on are e t r qu iv e ip l, is sec. in = h0.20 us on to s cal leve lipe s is f by T ca big box his of of ace sy wo al second h ly t ber pl ea e t rtic the a c be g th ve of f t ea ltip um s. o a u d e m 6 secondsin M e n on h r m t e . sa ft a sid er es) t th sec b r le ft m uar ve nto Description: e Description: n e l m l sq co es i Description: • Period from the start of the P wave to the Period r( e from al totheustart ar of the P wave to the beginning of the QRS complex beginning of the QRS complex m Period s from Indicates conduction timeP wave to the beginning of the QRS complex 4 the sq start of the • Indicates AV conduction time 0AV . l l aseconds • 0.12 to 0.20 seconds Indicates AV conduction time 0.12 to 00.20 sm  0.12 to 0.20 seconds

PR INTERVAL

QRS COMPLEX QRS COMPLEX

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PREHOSPITAL EMERGENCY CARE

353

Description:  Period from the start of the P wave to the beginning of the QRS complex Day 14  Indicates AV conduction time  0.12 to 0.20 seconds

BASIC ECG READING

QRS COMPLEX

QRS COMPLEX

UNIT 3 DAY UNIT14 3

DAY 14

PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLES OF EMT CLINICAL PRACTICE

Description: • Indicates ventricular depolarization or contraction of the ventricles • Less than 0.12 seconds • R waves are deflected positively and the Q and S waves are negative.

Description: ST SEGMENT  Indicates ventricular depolarization or contraction of the ventricles Less than 0.12 seconds STSEGMENT  R waves are deflected positively and the Q and S waves are negative.

ST SEGMENT

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

Description:  Indicates early ventricular repolarization Description:  Isoelectric  Indicates early ventricular repolarization Isoelectric T WAVE

Description: • Indicates early ventricular repolarization • Isoelectric

T WAVE

T WAVE

Description: • Indicates ventricular repolarization • Rounded and asymmetrical Description:  Indicates ventricular repolarization Description:  Rounded and asymmetrical  Indicates ventricular repolarization • and One of the first things you want to measure is the electrical rate of the heart.  Rounded asymmetrical DETERMINING THE RATE

DETERMINING THE RATE

• “Electrical” because you cannot measure the true heart rate with an ECG machine.

• The true heart rate is the rate at which the heart pumps blood. This is detected by taking a pulse.

DETERMINING THE RATE  One of • theIn the normal, healthy heart, the true rate will coincide with the electrical rate. first things you want to measure is the electrical rate of the heart.

• However, there are many reasons why there might not be a corresponding pulse to go with an  “Electrical” because you cannot measure the true heart rate with an ECG  One of theelectrical beat. first things you want to measure is the electrical rate of the heart. machine.  “Electrical” because you theheart true pumps heart rate with anisECG The true heart rate is thecannot rate atmeasure which the blood.

This demachine. tected by taking a pulse.

 The true heart healthy rate is the ratethe at which thewill heart pumpswith blood. is deIn the normal, heart, true rate coincide theThis electrical 354 LIFELINE PREHOSPITAL EMERGENCY CARE tected rate. by taking a pulse.

 In the normal, heart, the true coincide the electrical However, therehealthy are many reasons why rate therewill might not bewith a corresponding rate. pulse to go with an electrical beat.

 However, there are many reasons why there might not be a corresponding pulse to go with an electrical beat.

The R—R I

R—R I ThisThe is a measur distance The betwee R—R I secutive Th This is abeats. measur usually to distancechosen betwee This isit aisbeats. measur cause the tal secutive Th distance betwee Thechosen R—R In conspicuous. usually to secutive beats.

Th cause it is the tal usually chosen to conspicuous.

This is a measure cause it is the tal distance between conspicuous. secutive beats. Th usually chosen to cause it is the talle conspicuous.

DAY UNIT14 3 DAY UNIT14 3 DAY 14 UNIT 3 DAY 14

Interval

Interval rement of the en two conInterval

he R Wave is rement of the o do thisconbeen two rement ofmost the llest he Rand Wave is en two nterval o do thisconbehe Rand Wave is llest most o do this beement of the llest and most n two conhe R Wave is o do this beest and most

PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLES OF EMT CLINICAL PRACTICE

INTERPRETATION OF ARRHYTHMIAS FROM THE ECG

INTERPRETATION OF ARRHYTHMIAS FROM THE ECG PRINCIPLES OF(Atrial EMTand CLINICAL 1.

Calculate heart rate Ventricular) PRACTICE INTERPRETATION OF FROM  Atrial rate - Number of PARRHYTHMIAS Waves multiply by 10 (# of PTHE wavesECG X 10) 1. Calculate heart rate (Atrial and Ventricular)  Ventricular rate—Number of R Waves multiply by 10 (# of R waves X 10)  Atrial rateYou -heart Number Waves multiply byaccomplish 10 (# of P waves Note: needrate a of (6)P(Atrial Six second stripVentricular) to this. X 10) 1. Calculate and Ventricular rate—Number of R of Waves multiply bybetween 10 (# of R waves QRS X 10)ComINTERPRETATION OF ARRHYTHMIAS FROM THE ECG  300 divided by the number large squares regular  Atrial rate - Number of P Waves multiply by 10 (# of P waves X 10)

INTERPRETATION OF ARRHYTHMIAS FROM THE ECG 1. Calculate Heart Rate (Atrial and Ventricular) Note: You need a (6) Six second strip to accomplish this. plexes.

Ventricular rate—Number of R Waves multiply by 10 (# of R waves X 10)

 300 divided by the number of large squares between regular QRS Com-

Note: You need a (6) Six second strip to accomplish this.

1. Calculate plexes. heart rate (Atrial and Ventricular)

300 divided by the of number ofmultiply large squares regular Atrial rate - Number P Waves by 10 (#between of P waves X 10) QRS Complexes.  Ventricular rate—Number of R Waves multiply by 10 (# of R waves X 10) Note: You need a (6) Six second strip to accomplish this.

 300 divided by the number of large squares between regular QRS Complexes.

• Atrial rate - Number of P Waves multiply by 10 (# of P waves X 10) • Ventricular rate - Number of R Waves multiply by 10 (# of R waves X 10) 2.

Check for Regularity of Rhythm Note: You need a (6) Six second strip to accomplish this.  check for the equality of R—R Distance • Check 300 divided by the number of large squares between regular QRS Complexes.

2. for Regularity of Rhythm check for theRegularity equality of R—R 2. Check for of Distance Rhythm

2. Check for Regularity of Rhythm check for the equality of R—R Distance 2. Check for Regularity of Rhythm  check for the equality of R—R Distance

3. Rhythm

 Is there a P wave for every QRS?

check for the equality of R—R Distance

3.• Rhythm If YES = Sinus and/or Normal Rhythm If NOa =P Atrial Pattern  Is there wave Fibrillation for every QRS? 3. Rhythm If YES = Sinus and/or Normal Rhythm

3. PIs there Wave Relationship wave for every QRS? If NOa =P Atrial Fibrillation Pattern If YES = Sinus and/or Normal Rhythm

If NO = Atrial Fibrillation Pattern 3. Rhythm

 Is there a P wave for every QRS?

Ang R-R interval ay ang layo ng pagitan ng dalawang magkasunod na pagtibok ng puso. Ang R Wave ang kadalasang sinusuri dahil ito ang pinakamataas sa graph at pinakamadaling makita.

If YES = Sinus and/or Normal Rhythm If NO = Atrial Fibrillation Pattern

4. Measure the PR Interval • Is there a P wave for every QRS? 5. Measure the QRS Interval If YES = Sinus and/or Normal Rhythm

4. Measure the PR Interval If NO = Atrial Fibrillation Pattern 5.

Measure the the PR QRSInterval Interval 4. Measure 5. Measure the QRS Interval

4. Measure the PR Interval 4. Measure the PR Interval 5.Measure Measurethethe Interval 5.

QRS QRS Interval ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

LIFELINE

PREHOSPITAL EMERGENCY CARE

355

UNIT 3 DAY 14

Irregular

 QRS: Normal PRACTICE PRINCIPLES OF EMT CLINICAL P Waves: Sinus  Conduction: PR Normal or  QRS: Normal

slightly prolonged at slower  Conduction: PR Normal o PRINCIPLES OF EMT CLINICAL Day 14 rates.PRACTICE SINUS RHYTHM slightly prolonged at slow rates.

Sinus rhythms are those that arise fromARREST the pacemaker in the sinus node (also 3. SINUS or BLOCK called the SA node). The sinus pacemaker is our heart’s normal pacemaker. We have three basic rhythms that originate sinus node. theVentricular heart’s rate is All in the Atrial and Sinus rhythms are those that arise from the pacemaker in the sinus node (also called the SA node). The sinus 3.SINUS ARREST or IfBLOCK below 60 beats per minute (bpm), the rhythm is called SINUS BRADYCARDIA. If pacemaker is our heart’s normal pacemaker. We have three basic rhythms that originate in the sinus node. If the rhythms is normal except for the rate is above 100 beats per minute (bpm), rhythm is called TACHY All theAtrial andSINUS Ventricul heart’s rate is below 60 beats per minute (bpm), the rhythm is called SINUS BRADYCARDIA. If the rate is above CARDIA. If everything is just right, the rhythm is called NORMAL SINUS RHYTHM. 100 beats per minute (bpm), the rhythm is called SINUS TACHYCARDIA. If everything is just right, the rhythm missing complex. rhythms is normal except fo is called NORMAL SINUS RHYTHM. One reason is that an impulse that in thePsinus node follows a certain originates Normal Wave preceding missing complex.

One reason is that an impulse that originates in the sinus node follows a certain path that allows the atria to path that allows the atria to contract before the ventricles. Between the atria and contract before the ventricles. Between the atria and the ventricles is the AV Node. Conduction of the electrical each Complex.  Normal P impulse Waveslows precedin the ventricles is the AV Node. Conduction ofQRS the electrical down impulse slows down in the AV Node, allowing the atria to completely depolarize before the ventricles so that atria in the AV Node, allowing the atria to completely depolarize before the ventricles may contract first. each QRS Complex. so that atria may contract first.

SINUS RHYTHM

ARRHYTHMIAS

SINUS ARRHYTHMIA

SINUS ARRHYTHMIA

Arrhythmia is a term used when either the rate, rhythm, or contour of the “ individual waves does not meet normal “ standards.

UNIT 3 Classification of Arrhythmias:

DAY 14

1. Disturbance of impulse formation—according to site of origin 2. Disturbance of conduction— abnormal delay or block in the passage of the cardiac impulse from the SA Node thru the Purkinje Fibers in the ventricles.

.

Atrial Arrhythmias Atrial Arrhythmias

Premature Atrial Contraction (PAC) PRINCIPLES OF 1.EMT CLINICAL 1. Premature Atrial PRACTICE Contraction (PA

Sinus Arrhythmia is similar to Normal Sinus Rhythm except that sinus with Sinus Arrhythmia is similar to A Normal Sinusrhythm Rhythm except thattwo its rateprematu is irreguits rate is irregular. Id often matches the patient’s breathing pattern, A sinus rhythm with two prema lar. Id often matches the patient’s breathing pattern, speeding up when the pamaker fire prematurely, it is entirely speeding up when the patient inhales and slowing down when the patient tient inhales and slowing down when the patient exhales.

Sinus arrhythmia can makersituations, fire prematurely, it is entire exhales. Sinus arrhythmia can be relatively common in young and is often Rate: usually 100 to 150 bpm Inandthese be relatively common in young is often asymptomatic. you might find asymptomatic.

Rhythm: Regular these situations, you might fin plexInand T Waves.

We describe this How irregular is irregular? The criterion used by many is that the irregular is irregular? The criterion used by many is that the longest R-R How P Waves: Normal plex and T Waves. We describe th longest R-R interval should differ from the shortest by at least 0.16 seconds. shouldNormal differ from the shortest by at least 0.16 seconds. interval PR Interval:

 QRS: Normal

ARRHYTHMIAS Arrhythmias starting in the SA Node

1. SINUS “ TACHYCARDIA

.

 Rate: Normal or Accelerated  Rate: Normal or Accelerated  PWave: Usually have a differ P Wave: Usually have a diff

Arrhythmia is a term used when either the rate, rhythm, or contour of the indi2. SINUS BRADYCARDIA 2. SINUS BRADYCARDIA ent morphology than sinus

F EMT CLINICAL PRACTICE

150 bpm

P

vidual waves does not meet normal standards. ent morphology than sinus Sinus Tachycardia occurs when the sinus node created Sinus Bradycardia occurs when the sinus node creates Waves because they Sinus Bradycardia occurs when the sinus node creates an impulse atoriginate a slower Waves because they origina an impulse at a faster than normal rate. It may be caused by an impulse at a slower than normal rate. That may be caused Classification of Arrhythmias: than normal rate.

That may be caused by lower metabolic needs (e.g. sleep, from an ectopic pacemaker acute blood loss, shock and hypovolemia, anemia, congestive by lower metabolic needs (e.g. sleep, athletic training, from an ectopic 1. Disturbance of impulse formation—according to(e.g. site of origin pacemaker athletic training, hypothermia), vagal stimulation vomiting, suctioning), heart failure (CHF), Pain, Hypermetabolic states, fever, hypothermia), vagal stimulation (e.g. vomiting, suctioning), 2. Disturbance of conduction—abnormal delay or blockchannel in the passage of the QRS: Normal medications (e.g. beta blockers, amiodarone, calcium blockers), InQRS: Normal exercise, anxiety and sympathomimetic medications medications (e.g. beta blockers, amiodarone, calcium cardiac impulse from the SA Node thru the Purkinje Fibers in the ventricles. creased Intracranial Pressure (ICP) and Myocardial Infarction (MI) especially of channel blockers), Increased Intracranial Pressure (ICP) and Conduction: Normal Conduction: Normal the inferior wall Myocardial Infarction (MI) especially of the inferior wall of of the heart. the heart.

Arrhythmias starting in the SA Node PACs occur early in Rhythm:

      Rhythm: PACs occur early

 Rate: 40 to 59 bpm • Rate: 40 to 59 bpm SINUS TACHYCARDIA 1.Rhythm: Regular or Slightly • Rhythm: Regular Irregular

thethe cycle cycle

or Slightly

Tachycardia occurs when the sinus node created an impulse at a faster Irregular  PSinus Waves: Sinusrate. than normal It may be caused by acute blood loss, shock and hypo• P Waves: Sinus  QRS: Normal volemia, anemia, congestive states, • QRS: Normal heart failure (CHF), Pain, Hypermetabolic “ fever, exercise, anxiety and sympathomimetic medications  Conduction: PR Normal or • Conduction: PR

• Rate: usually 100 to 150 bpm slightly prolonged at slower Normal or slightly • Rhythm: Regular rates. prolonged at • P Waves: Normal slower rates.² Limmer ² Limmer (Brady) • PR Interval: Normal (Brady) the sinus node creates an impulse at a slower ³ Pollack, (AAOS) 3.

SINUS ARREST or BLOCK ³ Pollack, (AAOS) • QRS: Normal caused by lower metabolic needs (e.g. sleep,

when may be ⁴ NHTSA ⁴ NHTSA  All Atrial and Ventricular ermia), vagal stimulation (e.g. vomiting, suctioning), 356 LIFELINE PREHOSPITAL EMERGENCY CARE rhythms is normal except for lockers, amiodarone, calcium channel blockers),missing In- complex. ure (ICP) and Myocardial Infarction (MI) especially of(Brady) ² Limmer  Normal Wave preceding ³ Pollack, (AAOS) P ⁴ NHTSA art. each QRS Complex.

“

or wer

lar or

ng

UNIT 3 DAY 14

PRINCIPLES OF EMT CLINICAL PRACTICE

3. SINUS ARREST or BLOCK

2. Supraventricular Tachycardia (SVT)

2. Supraventricular Tachycardia (SVT)  Atrial and Ventricular rates regular  Heart Rate is >160bpm ; rarely exceeds 250bpm UNIT 3  P Waves regular not aberrant; difficult to differentiate from DAY 14 preceding T Wave  P Wave preceding each QRS • All Atrial and Ventricular rhythms is normal Complex • Atrial and Ventricular rates regular 2. Supraventricular Tachycardia (SVT)and termination except for missing complex.

Note: PAROXYSMAL—if onset of arrhythmia is sudden.

• Heart Rate is >160bpm ; rarely exceeds 250bpm • Normal P Wave preceding each QRS Complex.  Atrial and Ventricular rates • P Waves regular not aberrant; difficult to

PRINCIPLES OF EMT CLINICAL PRACTICE

regular differentiate from preceding T Wave • P Wave preceding each QRS Complex  Heart Rate is >160bpm ; rarely 3. Atrial Flutter exceeds 250bpm ) AC)  Ptooth” Wavesisregular notused aberrant; PAROXYSMAL—if onset and “Saw the term in describing Atrial Flutter because the P Waves difficult to differentiate from termination of arrhythmia is sudden ure Atrial complexes.

When paceoften looks an like Atrial the teeth of a saw when viewed in Lead II. These P waves are preceding T Wave Atrialthat complexes.

When an Atrial pace-The AV Node will normally only conduct impulses often calledis“Flutter waves”. yature possible the AV node still refractory.

A sinus rhythm with two premature Atrial complexes.  P Wave preceding each QRS that the AVtonode stillQRS refractory. up awithout rateisaround 220 per minute. In Atrial Flutter, the atria are depolarizing dely a possible singleWhen an Atrial pacemaker fire prematurely, it is entirely Atrial P Wave ComComplex “Saw tooth” is the term used in describing Atrial Flutter possible that the AV node is still refractory. In these at an extremely rapid rate, about to 350 times per minute.

This means that single Atrial P Wave QRS ComNote: without PAROXYSMAL—if onset and250 termination of arrhythmia is sudden. snd as anon-conducted. because the P Waves often looks like the teeth of a saw when situations, you might find a single Atrial P Wave without

Atrial Arrhythmias

1. Premature Atrial Contraction (PAC)

NOTE:

3. Atrial Flutter

not all of the impulses will be conducted. The conduction ratio (P: QRS ratio) is his as non-conducted. viewed in Lead II. These P waves are often called “Flutter QRS Complex and T Waves. We describe this as nonconducted.

rferP s P eate

often relatively constant at 2:1 or waves”. The AV Node will normally only conduct impulses up 4:1, although it can also vary. With 2:1 conto a rate around 220 per minute. In Atrial Flutter, the atria are duction, the ventricular rate is usually about 150. unlike Atrial Fibrillation, 3. Atrial Flutter depolarizing at an extremely rapid rate, about 250 to 350 times Atrial Flutter QRS Complexes tend to appear at regular intervals. per minute. This means that not all of the impulses will be

“Saw tooth” is the term used in describing Atrial Flutter because the P Waves conducted. The conduction ratio (P: QRS ratio) is often relatively often looks like the teeth220 of a saw when viewed in Lead II. These P waves are constant at 2:1 or 4:1, although it can also vary. With 2:1 con Atrial Heart Rate: to 430 often called “Flutter waves”. The AV duction, the ventricular rate is usually about 150. unlike Atrial Node will normally only conduct impulses bpm up to a rate around 220 per minute.Fibrillation, Atrial Flutter QRS Complexes tend to appear at In Atrial Flutter, the atria are depolarizing regular intervals.  Ventricular Heart Rate: <300 at an extremely rapid rate, about 250 to 350 times per minute. This means that Atrial Heart Rate: 220 to 430 bpm notbpm all of the impulses will be conducted.• The conduction ratio (P: QRS ratio) is • Ventricular Heart Rate: <300 bpm often relatively constant at 2:1 or 4:1, although it can also vary. With 2:1 con Rhythm: Regular • Rhythm: Regular duction, the ventricular rate is usually • about 150. unlike Atrial Fibrillation, P Wave: Saw toothed appearance  P Wave: Saw toothed appearAtrial Flutter QRS Complexes tend to appear at regular intervals.

• PR Interval (in seconds): NA

n in • •

• • •

ance • QRS (in seconds): > 0.12 Rate: Normal or Accelerated PR Interval (in seconds): NA Atrial Heart Rate: 220 to 430 P Wave: Usually have a different bpm(in seconds): > 0.12  QRS morphology than sinus P Waves because they originate from an ectopic  Ventricular Heart Rate: <300 pacemaker bpm 4. Atrial Fibrillation QRS: Normal  Rhythm: Regular Conduction: Normal Rhythm: PACs occur early in the cycle Fibrillation means “quivering”. Atrial Fibrillation often called “a-fib” is The  Pword Wave: Saw toothed appearance common among the elderly. It occurs when the electricity in the relatively  PRfollows Interval a(inseemingly seconds): NA Atria random and repetitive path, causing the Atria to quiver.

Because the Atria are quivering, they are unable to pump blood. There  QRS (in seconds): > 0.12 PREHOSPITAL EMERGENCY CARE 357 are a few reasons why this rhythm is bad. Some of themLIFELINE are: (A) the ventricles 4.may Atrialbe Fibrillation depolarized at too high a rate. The Atria are unable to perform their normal function and (B) Clots may form in the left atrium, predisposing the means Fibrillation often called is themThe word patient to Fibrillation a stroke. One of“quivering”. the major Atrial questions that doctors are“a-fib” asking

Day 14

PRINCIPLES OF EMT CLINICAL PRACTICE

4. Atrial Fibrillation

The word fibrillation means “quivering”. Atrial fibrillation often called “a-fib” is relatively common among the elderly. It occurs when the electricity in the atria follows a seemingly random and repetitive path, causing the Atria to quiver. Because the Atria are quivering, they are unable to pump blood. There are UNIT 3 UNIT 3 a few reasons why this rhythm is bad. Some of them are: (A) the ventricles may be depolarized at too high DAY 14 DAY a rate. The Atria are unable to perform their normal function and (B) Clots may form in the left atrium, UNIT14 3 predisposing the patient to a stroke. One of the major questions that doctors are asking themselves is: “Is DAY 14 it better to control or convert?”. CONTROL refers to controlling the rate. Keeping the rate of ventricular contraction under 100 bpm often mini-mizes the symptoms of this rhythm. This is usually done with  Rate: Atrial rate usually between Conduction Disord medication. When the rate of QRS complexes (and thus ventricular depolarization) exceeds 100, we call this 400 to 650 bpm rhythm Uncontrolled Atrial Fibrillation. CONVERT refers to converting the rhythm into a sinus rhythm.  Atrial usually between  Rate: P wave: notrate present; only fibrillaThis would be the obvious choice however, someone who has been in Atrial Fibrillation for a while has a high 400 to 650 bpm 1. First (1st) Degree AV B tory waves chance of “throwing clots” in the left atrium. These thrombi (clots) are thought to form in the Atria when  P wave: not present; only fibrilla Atrial and Ventric  QRS: Normal they are fibrillating. In the process of conversion to a sinus rhythm, tory waves Variable Regular  Conduction: the thrombi may become dislodged from the atrium. They are then  Rate: Atrial rate usually between  Normal  PR Interval > 0.20 s  QRS: Rhythm: Irregularly Irregular likely to be sent through the left ventricle, the Aorta, and into the 400 to 650 bpm  Conduction: (HALLMARK Variable Sign) Arteries that supply the brain. This could lead to a stroke. Patients  P Wave precedes Q  Rhythm: Irregularly Irregular who undergo this “cardioversion” are often put on anticoagulants  P wave: not present;(HALLMARK only fibrilla QRS Complex Norm Sign) for weeks before the procedure.

Junctional Rhythm

UNIT 3 DAY 14

• • • • •

PRINCIPLES O PRINCIPLES OF EMT CLINICAL PRACTICE PRINCIPLES OF EMT CLINICAL PRACTICE

PRINCIPLES OF EMT CLINICAL PRACTICE

tory waves

Rate: Atrial rate usually between 400 to 650 bpm  QRS: Normal Junctional Junction refersRhythm to the AV Junction, the area around the AV Node and the BunP wave: not present; only fibrilla-tory waves dle of His. A Junctional Rhythm is one that starts in the AV Junction.

When a UNIT 3 QRS: Normal  Conduction: Variable Junction refers to the AV Junction, area around theitAV Node2.Second and the Bunpacemaker in the junction fires andthe it travels “forward” produces an upright P(2nd) Degre Conduction: Variable DAY 14 dle of His. A it Junctional Rhythm is (backward) one that starts the AV Junction.

When a Wave, when travels “retrograde” the Pinwave is inverted. (i.e. upside  Rhythm: Irregularly Irregular (Mobitz Type I) Rhythm: Irregularly Irregular (HALLMARK Sign) pacemaker in the Isoelectric junction fires and it travels “forward” it produces upright Pdown, below line).

Thus an inverted P wave strongly an indicates that (HALLMARK Sign) Atrial Rhythm Regu Wave, when itimpulse travels originate “retrograde” (backward) P wave is inverted.  (i.e. upside the electrical in the AV Nodethe or beyond. down, below the Isoelectric line). Thus an inverted P wave strongly indicates that  Ventricular Rhythm the electricaltoimpulse originate in the AVJunctional Node or beyond.

In addition being upside-down, the P wave may not beConduction before the Diso  PR Interval prog QRS. When the sinus fires, the Atria are depolarized before the ventricles, and only slightly longe In addition being upside-down, the Junctional wave may may not be before the thus the P to wave is first.

In a Junctional Rhythm, Pthe P wave occur before, cycleand until QRS Co 1. First (1st) Degree A QRS. When thethe sinus the Atria are depolarized before the ventricles, during or after QRSfires, Complex.

Junction refers to the AV Junction refers to the thus AV the Junction, area aroundRhythm, the AV thepears Bun(dropped be P wave is the first. In a Junctional the Node P wave and may occur before,  Atrial and Ven Junction, the area around the AV val shorter after dro during or afterJunctional the 1. Premature Complex (PJC) in the AV Junction. When dle of His. A Junctional Rhythm is QRS oneComplex. that starts a Regular “ Node and the Bundle of His. A A Premature Junctional pacemaker in the junction fires and it travels “forward” it produces an upright P PR Interval > 0.2 Junctional Rhythm is one that 1. Premature Junctional Complex (PJC) A Premature Junctional Complex is Complex is not a rhythm but Wave, when it travels “retrograde” (backward) thea P wave is inverted. (i.e. upside starts in the AV Junction. When  P Wave notrather denotes a complex a rhythm but rather denotes 3.Second (2nd) precede Degre a pacemaker in the junction fires A Premature Junctional is P wave strongly indicates complex caused byan a Complex Junctional down, below the Isoelectric line).

Thus inverted that (Mobitz Type II)  QRS Complex N caused by a Junctional not a rhythm butinterrupts rather denotes a pacemaker that the unand it travels “forward” it produces the electrical impulse originate in the AV Node or beyond.  Atrial Rate Regular pacemaker that interrupts complex caused by a Junctional derlying rhythm. an upright P-Wave, when it travels the underlying rhythm.  Ventricular Rhythm pacemaker that interrupts the un“retrograde” (backward) the P wave Irregular derlying rhythm.

In addition to being upside-down, the Junctional P wave may not be before the with varyi is inverted. (i.e. upside down, below Block the Isoelectric line). Thus an inverted QRS. When the sinus fires, the Atria are depolarized before the ventricles, and (2nd) De 2.Second  P to P Interval is co P wave strongly indicates that the thus the P wave is first.

In a Junctional Rhythm, the P wave may occur before, (Mobitz Type I) 2. Junctional Tachycardia electrical impulse originate in the AV  QRS Complexes  Atrial Rhythm R during or after the QRS Complex.

Node or beyond. “ absent 2. Junctional An ectopicTachycardia pacemaker in the AV  Ventricular Rhyt In addition to being upsideJunction decides to overtake the An ectopic pacemaker “ down, the Junctional P wave may not  PR Interval pr 1. Premature JunctionalAn Complex (PJC) ectopic in the of AVa sinus node. pacemaker This is equivalent in the AV Junction decides to be before the QRS. When the sinus only slightly lo Junction to overtake coup, led decides by a trouble maker in the the “ is faster fires, the Atria are depolarized before sinus node. This of a AVovertake the sinus node. This Junction.

If is theequivalent rate QRS 4.Third cycle (3rd) until Degree is equivalent of a coup, led A Premature Junctional Complex is call the ventricles, and thus the P wave coup, led by a trouble maker the than 100 bpm, we this inJuncpearsHeart (dropped (Complete Block by a trouble maker in the AV is first. In a Junctional Rhythm, the AV Junction.

If the not a rhythm but rather denotes a rate is faster tional Tachycardia. valRate shorter after  Atrial Regular Junction. If the rate is faster than 100 bpm, we P wave may occur before, during or complex caused by athan 100 bpm, we call this Junctional call this Junc Ventricular Rate tional Tachycardia. after the QRS Complex. pacemaker that interrupts theJunctional un- Rhythm Junctional Tachycardia.

3. Accelerated regular 3.Second (2nd) De derlying rhythm.  (Mobitz No Relation betw Type II) 3. Accelerated Occasionally,Junctional an ectopicRhythm pacemaker and QRS Complexe  Atrial Rate Regu in the AV Junction will have a rate  No Constant PR Int Occasionally, an ectopic that is too fast to be pacemaker considered 358 LIFELINE  Ventricular Rhy PREHOSPITAL EMERGENCY CARE in the AV Junction will too haveslow a rate Junctional escape but to  QRSIrregular Interval with is Norva that is too fastJunctional to be considered be considered TachycarBlock Junctional escape slow to dia. We call this but as too Accelerated  P to P Interval is 2. Junctional Tachycardia be considered Junctional TachycarJunctional Rhythm. dia. We call this as Accelerated  QRS Complex

PRINCIPLES

Junctional Junctional RhythmRhythm

1. Premature Junctional Complex (PJC)

2. Junctional Tachycardia

PRINCIPLES EMT If the rate isOF faster DAYAV14Junction. than 100 bpm, we call this Junctional Tachycardia.

CLINICAL PRACTICE

Conduction Disorders 3. Accelerated Junctional Rhythm

3.

UNIT 31. First (1st) Degree AV Block Occasionally, an ectopic pacemaker  Atrial and Ventricular Rhythms PRINCIPLES OF EMT DAY 14 Regular in the AV Junction will have a rate Accelerated Junctional Rhythm

CLINICAL PRACTICE

seconds that is too PR fastInterval to be> 0.20 considered Occasionally, an ectopic pacemaker in the Junctional escape too slow to P Wavebut precedes QRS Complex AV Junction will have a rate that is too fast to be be considered Junctional Tachycar QRS Complex Normal Conduction Disorders considered Junctional escape but too slow to be dia. We call this as Accelerated considered Junctional Tachycardia. We call this Junctional 1.

Rhythm. as Accelerated Junctional Rhythm.

First (1st) Degree AV Block  Atrial and Ventricular Rhythms 2.SecondRegular (2nd) Degree AV Block  PRType Interval (Mobitz I) > 0.20 seconds ders  P Wave precedes  Atrial Rhythm RegularQRS Complex  QRS Complex Normal  Ventricular Rhythm Irregular Block  PR Interval progressively, but3. Second (2nd) Degree AV Block cular Rhythms only slightly longer with each (Mobitz Type II) ² Limmer (Brady) ³ Pollack, (AAOS) cycle until QRS Complex disap- • Atrial Rate Regular ⁴ NHTSA seconds pears (dropped beat); PR Inter- • Ventricular Rhythm Regular or Irregular with 2.Second (2nd) QRS Complex val shorter after Degree dropped AV beat.Block varying Degree of Block (Mobitz Type I) • P to P Interval is constant mal  Atrial Rhythm Regular • QRS Complexes periodically absent 3.Second (2nd) Degree Block  Ventricular RhythmAV Irregular (Mobitz II)  PRType Interval progressively, but  Atrial Rate Regular only slightly longer with each

ee AV Block 1. First (1st) Degree AV Block cycle until QRS Complex  Ventricular Rhythm Regular disapor • Atrial and Ventricular Rhythms Regular pears (dropped beat); PR of InterIrregular with varying Degree • PR Interval > 0.20 seconds val shorter after dropped beat. ular Block • P Wave precedes QRS Complex m Irregular  P to P Interval is constant • QRS Complex Normal orders but gressively,  QRS Complexes periodically 3.Second ger with each absent (2nd) Degree AV Block (Mobitz Type II) omplex disapAV Block  Atrial Rate Regular eat); PR Interntricular Rhythms  Ventricular Rhythm Regular or opped beat. “ with varying 4.Third Irregular (3rd) Degree AV Degree Block of 20 seconds 2. Second (2nd) Degree(Complete AV Block 4. Third (3rd) Degree AV Block BlockHeart Block) es QRS Complex (Mobitz Type I) (Complete Heart Block) ee AV Block  P toRate P Interval  Atrial Regularis constant • Atrial Rhythm Regular • Atrial Rate Regular Normal  QRS Complexes periodically  Ventricular Rate is slow and • Ventricular Rhythm Irregular • Ventricular Rate is slow and regular absent regular • PR Interval progressively, but only slightly longer • No Relation between P waves and QRS Complexes m Regular or  No Relation between P waves • No Constant PR Interval with each cycle until QRS Complex disappears ing Degree of and QRS Complexes (dropped beat); PR Interval shorter after dropped • QRS Interval is Normal beat.  No Constant PR Interval “ egree AV Block 4.Third (3rd) Degree AV Block onstant  (Complete QRS Interval is Normal Heart Block) periodically Regular  Atrial Rate Regular thm Irregular  Ventricular Rate is slow and rogressively, but regular onger with each  No Relation between P waves Se Complex disapAV Block and QRS Complexes dk) beat); PR Inter No Constant PR Interval r dropped beat.  QRS Interval is Normal is slow and

OF EMT CLINICAL PRACTICE

Conduction Disorders

S OF EMT CLINICAL PRACTICE

egree AV Block ween P waves es ular terval ythm Regular or rmal arying Degree of

s constant xes periodically

LIFELINE ² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

PREHOSPITAL EMERGENCY CARE

359

 QRS: wide > 0.12 seconds, bi- 3tion, relatively slow rate . Symptomatic: palpitations, breathlessness, lightUNIT headedness, angina and syncope are evident.

PRINCIPLES OF EMT CLINICAL PRACTICE

zarre morphology DAY 14  Conduction: Impulse originates  Rate: Usually between 100 to 250 bpm below the branching portion of  P Wave: obscured the Bundle of His  QRS: Wide and Bizarre Day occur 14 Ventricular Arrhythmias  Rhythm: Irregular—may  Conduction: As with PVCs singly, in pairs, bigeminy,  Rhythm: Three or more ventricutrigeminy, or quadrigeminy 1. beats Premature Ventricular lar in a row, may beContractions reguRate: Variable lar orirregular P Wave: Usually obscured by the  Maystop or start suddenly 2. Ventricular Tachycardia QRS, PST or T Wave of the PVC “  QRS: wide > 0.12 seconds, biTORSADES DE POINTES Etiologies: Coronary Artery Disease, Non-ischemic Cardiomyopathies, Conzarre morphology genital Myocardial Defects, Infectious Disease, Inflammatory Disease affecting  Conduction: Impulse originates below the branching portion of Myocardium.

BASIC ECG READING

Ventricular Arrhythmias 1. Premature Ventricular Contractions

• Rate: Variable the Bundle of His • Asymptomatic P Wave: Usually obscured  Rhythm: occur in patients who is in supine position, Irregular—may preserved cardiac funcby the QRS, PST or T Wave singly, in breathlessness, pairs, bigeminy,lighttion, relatively slow rate . Symptomatic: palpitations, trigeminy, or quadrigeminy of the PVC angina and syncope are evident. headedness, • QRS: wide > 0.12 seconds, bizarre morphology 3. Ventricular Fibrillation  Rate: Usually between 100 to 250 bpm 2.Ventricular Ventricular Tachycardia 2.Ventricular Tachycardia •  Conduction: Impulse  Rhythm: Rapid and P Wave: obscured

Etiologies: Coronary Artery Disease, Non-ischemic Chaotic originates below the Etiologies: Coronary Artery Disease, Non-ischemic Cardiomyopathies, Con QRS: Wide and Bizarre Cardiomyopathies, Con-genital Myocardial Defects, Infectious  QRS Complex: Wide and irregu-Infectious Disease, Inflammatory Disease affecting genital Myocardial Defects, branching portion of the Disease, Inflammatory Disease affecting Myocardium.  Conduction: As with PVCs lar, No Visible P Waves Myocardium.

Bundle of His  Rhythm: Three or more ventricu- • Rhythm: Irregular—may Asymptomatic in patients who is in supine position, preserved cardiac funclar beats in a row, may be regu- Asymptomatic in patients who is in supine position, preserved occur singly, in pairs, tion, relatively slow rate . Symptomatic: palpitations, breathlessness, lightcardiac function, relatively slow rate . Symptomatic: palpitations, lar or irregular bigeminy, trigeminy, or headedness, angina and syncope are evident. breathlessness, light-headedness, angina and syncope are evident.  May stop or start suddenly quadrigeminy •  Rate: Usually between 100 to 250 bpm Rate: Usually between 100 to 250 bpm

S OF EMT CLINICAL PRACTICE

ythmias

ar Contractions

P Wave: obscured • P Wave: obscured

obscured by the ave of the PVC 12 seconds, bigy pulse originates ching portion of s lar—may occur irs, bigeminy, adrigeminy

TORSADES DE POINTES QRS: Wide and Bizarre • QRS: Wide and Bizarre

Conduction: As with PVCs • Conduction: As with PVCs Rhythm: Three or more ventricu• Rhythm: Three or more lar beats in a row, may be reguventricular beats in a row, lar or irregular may be regular or irregular May stop or start suddenly • May stop or start suddenly

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

“

TORSADES DE POINTES

3. Ventricular Fibrillation  Ventricular Rhythm: Rapid and Chaotic rdia  QRS Complex: Wide and irreguNo Visible P Waves ry Artery Disease, Non-ischemiclar, Cardiomyopathies, ConDefects, Infectious Disease, Inflammatory Disease affecting

UNIT 3 DAY 14 PRINCIPLES patients who is in supine position, preserved cardiac func-

w rate . Symptomatic: palpitations, breathlessness, lighta and syncope are evident.

3. Ventricular Fibrillation

3. Ventricular Fibrillation

OF EMT CLINICAL PRACTICE Ventricular Rhythm: Rapid and Chaotic

 QRS Complex: Wide and irregular, No Visible P Waves

Asystole (Ventricular Standstill) Asystole (Ventricular Standstill)

ween 100 to 250 bpm d Commonly called “flat line” is charac² Limmer (Brady) Commonly called “flat line” is characterized ³ Pollack, (AAOS) terized by absent QRS Complexes.

Bizarre ⁴ NHTSA by absent QRS Complexes. There is no heartbeat, There is no heartbeat, No palpable with PVCs No palpable Pulse, and No Respiration. Causes are Pulse, and No Respiration. Causes are r more ventricubased on AHA-ACLS Guidelines, these are the 5H’s based on AHA-ACLS Guidelines, these w, may be regu(Hypovolemia, Hypoxia, hydrogen Ions-Acidosis, are the 5H’s (Hypovolemia, Hypoxia, hydrogen Ions-Acidosis, ² Limmer Hypo/ Hypo/Hyperkalemia, Hypothermia) and 5T’s (Toxins, (Brady) (AAOS) Hyperkalemia, Hypothermia)⁴³ Pollack, and NHTSA 5T’s Tamponade, Tension Pneumothorax, Thrombosis, (Toxins, Tamponade, Tension PneuTrauma).

suddenly

TORSADES DE POINTES

360

LIFELINE

on hm: Rapid and

mothorax, Thrombosis, Trauma).

Automated External Defibrillator (AED)

PREHOSPITAL EMERGENCY CARE

• Ventricular Rhythm: “ Rapid and Chaotic • QRS Complex: Wide and irregular, No Visible P Waves

terized by absent QRS Complexes.

There is no heartbeat, No palpable Pulse, and No Respiration. Causes are based on AHA-ACLS Guidelines, these are the 5H’s (Hypovolemia, Hypoxia, hydrogen Ions-Acidosis, Hypo/ Hyperkalemia, Hypothermia) and 5T’s (Toxins, Tamponade, Tension Pneumothorax, Thrombosis, Trauma).

Automated External Defibrillator (AED) Automated External Defibrillator (AED)

Types of automated external defibrillators AED Safety Types of Automated External Defibrillators 1. Fully automated - defibrillator operates without action by EMT-Basic, except

1. Do not defibrilate soaking-wet patient 2. Do not defibrillate if patient is touching anything metallic that other people are voice synthesizer to advice touching its analysis of the patient's 3. Remove nitroglycerin patches before defibrillating 4. Verball and visually “CLEAR” patient before defibrillating 5. defibrilaltion can be performed on Classified by type of shock delivered patient with an implanted device 1. Monophasic – sends single shock from negative pad to 1. Monophasic – sends single shock from negative pad6. toposition defibrillation pads on patient’s positive pad positive pad chest to avoid contact with the device 2. Biphasic – sends shock in one direction and then the other Analyzes car2. Biphasic – sends shock in one direction and then diac rhythm to determine whether shock is indicated. Most common condithe other Analyzes cardiac rhythm to determine whether shock is indicated. Most common conditions tions resulting in cardiac arrest are shockable rhythms : Ventricular fibrillaresulting in cardiac arrest are shockable rhythms : Use checklist at beginning of every tion and Ventricular tachycardia Ventricular fibrillation and Ventricular tachycardia shift to ensure you have all supplies and AED is functioning properly. Make sure battery is charged and you have a spare with — Involves defibrillator multiple functions: 1. Fully automated - defibrillator operates without to turn on power. action by EMT-Basic, except to turn on power.

2. Semi-automated - defibrillator uses a computer 2. Semi-automated - defibrillator uses a computer voice synthesizer to advice EMT-Basic as to the EMT-Basic as to the steps to take based upon steps to take based upon its analysis of the patient’s cardiac rhythm cardiac rhythm

Classified by Type of Shock Delivered

AED Maintenance

AEDQuality Safety Improvement AED

1. Medical direction Do not defibrilate soaking-wet patient 2. 1.

Initial training 3. 2.

Maintenance of skills Do not defibrillate if patient is touching anything metallic that other people 4. Case review Interrupt CPR only when absolutely necessary and for are touching 5. Trend analysis as short period as possible, CPR must be caused for rhythm 6. 3.

Strengthening links in chain of Remove nitroglycerin patches before defibrillating analysis and defibrillation survival

Coordinating CPR and AED

4. Verball and visually “CLEAR” patient before defibrillating 5. defibrilaltion can be performed on patient with an implanted device 6. position defibrillation pads on patient’s chest to avoid contact with de- EMERGENCY CARE LIFELINE the PREHOSPITAL vice

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du 3. Pe an lie BASIC ECG READING Day 14 ECG PROCEDURE th ECG PROCEDURE ar 1. Prepare the necessary 1. Prepare the necessary 4. A equipment—ECG Ma c. Rate should be at least 100-120 per minute. w 1. Perform Primary Assessment equipment—ECG Ma • If bystanders are doing CPR when you arrive, chine, Recording paper, d. Rotate personnel through compressor of chine, Recording paper,

position to prevent fatigue.

have them stop.

Electrodes.

5. Ex

e. If patient wakes or begins to move.

• Verify pulselessness, apnea, absence of other Electrodes.

2. Verify Physician's order • Obtain baseline vital signs.

signs of life no longer than 10 secs. pu 2. Verify Physician's order

• Administer high-concentration oxygen and identify patient ac- • Transport.and identify patient acea 2. Patient Care

• Post-Resuscitaion Care cording to protocol.

Pro • Apply AED cording to protocol. Pro- 6. A Patient has a pulse.

a. Bare patient’s chest, quickly shave area where vide privacy and explain a. an • Manage airway; avoid hyperventilation. vide privacy and explain

pads will be placed if necessary. to the patient the proce- • Keep defibrillator on patient during no

b. If available, use pediatric AED pads. to the patient the proce transport in case patient goes back into yo dure.

c. If using adult pads, do not overlap.

arrest. dure.

• Use AED 3.

EC Perform hand hygiene • Reassess frequently (every 5 minutes).

a. Turn on AED. 3. Perform hand hygiene

• Consider hypothermia protocols.

7. Pr and advice the patient to

b. Attach pads to cables and then to patient. and advice the patient to

b. Patient goes back into cardiac arrest

c. Stop CPR and analyze. ob lie in supine position at • Stop vehicle, resume CPR. lie in supine position at

d. Clear patient and shock if indicated.

• Analyze rhythm as soon as possible. m the center of the bed with

e. Immediately begin CPR after delivering a the center of the bed with

• Deliver shock if indicated.

shock. le arms at sides.

• Continue high quality CPR. arms at sides.

f. Reassess patient after providing 2 minutes or 8.

A 4. Apply electrodes to the • Mechanical CPR devices—Assist EMTs

5 cycles of CPR or until AED analyzes.

4. Apply electrodes to the

to provide high-quality compressions (e.g. th

g. If AED finds no shockable ECG rhythm, will wrists and medial aspect

Thumper and Auto-pulse). wrists and medial aspect

advise that no shock is indicated. th of the ankles.

1.

• Pulseless electrical activity. of the ankles.

9. Cl

• Asystole 5. Expose client’s chest and3. Pediatric Considerations 5.

Expose client’s chest and

• Congenital condition.

h. Resume CPR immediately. eq put pre-gelled electrode at • Typically respiratory in nature.

• When providing CPR. put pre-gelled electrode at 10. La each electrode position.

a. Compressions must not be interrupted for each electrode position. w Geriatric Considerations any longer than 10 seconds.

2.

6. Ask the patient to lie still4.

• Watch for deterioration.

b. Compressions at least 2”-2.4” deep for adult 6. Ask the patient to lie still an and not talk, just breath • Past medical history significant.

and at least one-third depth of chest for and not talk, just breath da

infants and children with full chest recoil. normally and relax when normally and relax when tu you are recording the you are recording the 11. D ECG. ECG. 7. Press print button and 3.

7. Press print button and observe the tracing. The observe the tracing. The machine will record all 12 machine will record all 12 leads automatically. leads automatically.

• Dispatch Information – provides you with the first

of hypoxia, , Altered mental status, and

8. After recording, remove

indications that a patient may be suffering from

SpO2 less than 95%.

8. After recording, remove

cardiac compromise. the electrodes and clean• Secondary Assessment 4. the electrodes and clean • Scene Size-Up – ensure that the scene is secure i. History (OPQRST). the client’s skin.

• Primary Assessment ii. Fibrinolytics absolute and relative

the client’s skin.

9. Clean the used materials/ i. form a General Impression of the patient and his

contraindications (AHA).

9. Clean the used materials/

Mental Status as you approach the scene • Active bleeding (excluding menstrual cycles).

5. equipment. ii. ensure adequate airway, breathing, oxygenation, • Closed head trauma or facial trauma within

equipment.

10. Label the ECG recording

and circulation. Note: Patient’s skin color,

the past three months.

10. Label the ECG recording

temperature, condition, type, location and with: Patient’s name, Age • Ischemick stroke within the past three months.

• History of chronic, severe, or poorly

intensity of pain, presence of other signs and with: Patient’s name, Age 6. and Sex, Medical Record,

controlled hypertension.

symptoms and Sex, Medical Record, iii. Apply oxygen at 15 l pm via non

date and time, and signa- • Major surgery. date and time, and signa • Internal bleeding within the last two to four

rebreather mask – if any of these are ture.

weeks. ture.

present: Signs of respiratory distress, Signs 11. Document the procedure.

11. Document the procedure.

PATIENT ASSESSMENT

ASSESSMENT AND CARE: GENERAL GUIDELINES Assessment-Based Approach: Cardiac Compromise and Acute Coronary Syndrome

7.

ure. erform hand hygiene nd advice the patient to e in supine position at he center of the bed with rms at sides.

Apply electrodes to the Adequate breathing – administer oxygen by wrists and• medial aspect nonrebreather mask at 15 lpm. f the ankles.

• Inadequate breathing – provide positive pressure ventilation with supple-mental xpose client’s chest and oxygen. ut pre-gelled electrode at • Position of comfort, provide calm reassureance – decrease patient’s anxiety. ach electrode position.

• Assist with prescribed nitroglycerin.

Ask the patient to lie still • If local protocol permits and the patient nd not talk, just breath does not have known aspirin allergy – Reassessment - UNIT 3 administer 160 to 325 mg of nonenteric Continuous reassessment ormally and relax when aspirin; have the patient chew it. for any changes in ou are • recording the 14 Call for ALS back up; initiate early DAY patient’s condition transport.

CG. ress print button and bserve the tracing. The machine will record all 12 eads automatically.

After recording, remove ECG PROCEDURE he electrodes and clean he client’s Prepareskin. the necessary lean the used materials/ equipment—ECG Maquipment. chine, Recording paper, abel the ECG recording Electrodes. with:Verify Patient’s name, Age Physician's order ndand Sex, identify Medical patient Record,acatecording and time, and signa-Proto protocol.

2 ure.vide1 privacy and explain Document procedure. to the the patient the proce-

Emergency Medical Care

ECG PROCEDURE 1. Prepare the necessary equipment—ECG Machine, recording paper, electrodes.

2. Verify physician’s order and identify patient according to protocol. Provide privacy and explain to the patient the procedure.

3. Perform hand hygiene and advice the patient to lie in supine position at the center of the bed with arms at sides.

4. Apply electrodes to the wrists and medial aspect of the ankles.

5. Expose client’s chest and put pregelled electrode at each electrode position.

6. Ask the patient to lie still and not talk, just breath normally and relax when you are recording the ECG. 7. Press print button and observe the tracing. The machine will record all 12 leads automatically.

8. After recording, remove the electrodes and clean the client’s skin.

9. Clean the used materials/ equipment.

10. Label the ECG recording with: Patient’s name, age and sex, medical record, date and time, and signature.

11. Document the procedure.

PRINCIPLES OF EMT CLINICAL PRACT

dure.

Perform hand hygiene and advice the patient to lie in supine position at the center of the bed with arms at sides.

Apply electrodes to the wrists and medial aspect of the ankles.

Expose client’s chest and put pre-gelled electrode at each electrode position.

Ask the patient to lie still and3 not talk, just breath normally and relax when you are recording the ECG. Press print button and observe the tracing. The machine will record all 12

Kung mabuhok ang dibdib ng pasyente, posibleng ahitin muna ang isang bahagi nito para maikabit ang ECG electrodes.

4 LIFELINE

² Limmer (Brady) ³ Pollack, (AAOS) ⁴ NHTSA

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Day 14

LIMB LEAD PLACEMENT

BASIC ECG READING

RED = RA lead wire = Right arm YELLOW = LA lead wire = Left Arm BLACK = RL lead wire = Right Leg GREEN = LL lead wire = Left Leg

CHEST LEAD PLACEMENT V1 (red) • 4th intercostals space to the right of sternum V2 (yellow) • 4th intercostals space to the left of sternum V3 (green) • midway between V2 and V4 V4 (brown) • 5th intercostals space at mid-clavicular line

5

V5 (black) • anterior Axillary same level as V4 V6 (violet) • midaxillary line same level as V4 and V5

Wala kahit anumang panganib ang puwedeng idulot ng ECG sa pasyente.

Kaya hindi ito dapat katakutan.

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LIFELINE

PREHOSPITAL EMERGENCY CARE

² Limmer, O’Keefe, “Emergency Care”, 12th Edition. Brady, NJ (2012) ³ Pollack, “Emergency Care and Transport of Sick and Injured”, 10th Edition. AAOS, MS (2011) 4 National Highway and Traffic Safety Administration (NHTSA), “EMT Basic Standard Curriculum“, Department of Transportation, USA, (2005)

Lifeline in Action

THE MOST IMPORTANT TEACHER IN LIFELINE IS NOT HUMAN

LEARNING FROM SIMMAN We learn how to ride a bicycle not by reading books or sitting through lectures. We learn it by riding a bicycle.

The same goes through with Basic Life Support (BLS) and cardiopulmonary resuscitation (CPR). You will only learn it if you do it yourself.

In Lifeline Academy, our students get to do CPR with the aid of SimMan or Simulation Man, the first full-size CPR dummy in the country.

SimMan is a CPR manikin. And it has proven to be the most effective teacher in Lifeline Academy.

Through SimMan, Lifeline students are able

to experience how it is to give quality CPR. The quality of CPR is measured through compression rate, depth, release, and hands-off time. Palpable pulses, blood pressure and ECG waves are even generated to truly simulate the effect of CPR. Lifeline Academy students also learn from SimBaby, a child dummy that is more basic than SimMan. Lifeline Academy instructors say the CPR learning curve is shortened with the use of such manikins because the students immediately get feedback, both through manual feel and electronic sensors, telling them if what they are doing is helping the patient or not.

LIFELINE

PREHOSPITAL EMERGENCY CARE

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