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FCA 0811 - EMS Differential
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FCA 0811 - EMS Differential

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Redwood Memorial Hospital

Redwood Memorial Hospital
EMS Field Care Audit Lecture

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FCA 0811 - EMS Differential Presentation Transcript

  • 1. WHAT’S BEHIND DOOR NUMBER 2...? Veronica Bonales, M.D. CEPAmerica, Emergency Medicine EMCC Paramedic Coordinator
  • 2. 911, What’s your emergency?
  • 3. Responding to a Call
  • 4. Responding to a CallNeed the info
  • 5. Responding to a CallNeed the info Age
  • 6. Responding to a CallNeed the info Age Sex
  • 7. Responding to a CallNeed the info Age Sex Chief Complaint
  • 8. What are the possibilities?
  • 9. What are the possibilities?AKA the differential...
  • 10. What are the possibilities?AKA the differential... What could cause chief complaint?
  • 11. What are the possibilities?AKA the differential... What could cause chief complaint? What are issues related to age?
  • 12. What are the possibilities?AKA the differential... What could cause chief complaint? What are issues related to age? What are issues related to sex?
  • 13. Headache
  • 14. Headache
  • 15. Headache
  • 16. HeadacheMigraine
  • 17. HeadacheMigraine CVA
  • 18. Headache Migraine CVABleed
  • 19. Headache Migraine CVATrauma Bleed
  • 20. Headache Migraine CVATrauma Infection Bleed
  • 21. Headache Migraine CVA TumorTrauma Infection Bleed
  • 22. Headache Migraine CVA TumorTrauma Infection Bleed
  • 23. Headache Migraine CVA TumorTrauma Infection Bleed
  • 24. Headache Migraine CVA TumorTrauma Infection X Bleed
  • 25. Headache X Migraine CVA TumorTrauma Infection X Bleed
  • 26. Headache X Migraine X CVA TumorTrauma Infection X Bleed
  • 27. Chest Pain
  • 28. Chest Pain AGE-related CAUSES - infant SEX - Muscle/Skeletal - child - Male - Cardiac - teen- Female - Pulmonary - adult - GI - elderly
  • 29. Shortness of Breath
  • 30. Shortness of Breath CAUSES- Muscle/Skeletal - Cardiac - Pulmonary - GI
  • 31. Abdominal Pain
  • 32. Abdominal Pain
  • 33. Primum Non Nocere
  • 34. Arriving at the Scene
  • 35. Arriving at the SceneSurvey the sceneA - AirwayB - BreathingC - CirculationD - DisabilityE - Exposure
  • 36. VitalsHeart RateRespiratory RateBlood PressureTemperaturePain Scale
  • 37. Physical ExamFocused but thorough
  • 38. Clinical Scenarios
  • 39. 911 Call28 y.o. female c/oabdominal pain andvaginal bleeding.
  • 40. 911 Call28 y.o. female c/oabdominal pain andvaginal bleeding.
  • 41. What is the differential...??
  • 42. What is the differential...?? Ectopic pregnancy
  • 43. What is the differential...?? Ectopic pregnancy Ruptured ovarian cyst
  • 44. What is the differential...?? Ectopic pregnancy Ruptured ovarian cyst Dysparunia
  • 45. What is the differential...?? Ectopic pregnancy Ruptured ovarian cyst Dysparunia Complicated UTI
  • 46. What is the differential...?? Ectopic pregnancy Ruptured ovarian cyst Dysparunia Complicated UTI Trauma
  • 47. Behind door #1...Pain off and onsince last nightNow more intenseand more frequentcramping painNoticed blood afterwent to bathroom
  • 48. Behind door #1...Pain off and onsince last nightNow more intenseand more frequentcramping painNoticed blood afterwent to bathroom
  • 49. Now what...??
  • 50. Now what...??Imminent delivery
  • 51. Now what...??Imminent delivery Back-up
  • 52. Now what...??Imminent delivery Back-up Supplies
  • 53. Now what...??Imminent delivery Back-up Supplies Position
  • 54. Now what...??Imminent delivery Back-up Supplies Position Slow and controlled
  • 55. Now what...??
  • 56. Now what...?? Not this.....
  • 57. Now what...??
  • 58. Now what...??Place patient into position
  • 59. Now what...??Place patient into positionGloves or clean hands
  • 60. Now what...??Place patient into positionGloves or clean handsTowel and control the head
  • 61. Now what...??
  • 62. Now what...??Support head
  • 63. Now what...??Support headTell mother to stop pushingwhen head is out
  • 64. Now what...??Support headTell mother to stop pushingwhen head is outCheck for nucal cord
  • 65. Now what...??Support headTell mother to stop pushingwhen head is outCheck for nucal cordRemove if found
  • 66. Now what...??
  • 67. Now what...??Support head
  • 68. Now what...??Support headPull down then pull up todeliver each shoulder
  • 69. Now what...??Support headPull down then pull up todeliver each shoulderHold baby firm as will slideout easily
  • 70. Now what...??
  • 71. Now what...?? Protocols...
  • 72. Now what...?? Protocols... Lay baby on mother’s abdomen and transport
  • 73. Now what...?? Protocols... Lay baby on mother’s abdomen and transport Cut umbilical cord and transport
  • 74. Now what...?? Protocols... Lay baby on mother’s abdomen and transport Cut umbilical cord and transport Deliver placenta and transport
  • 75. Questions...?
  • 76. 911 Call40 something yearold male witnessedfall at bus stop
  • 77. 911 Call40 something yearold male witnessedfall at bus stop
  • 78. What is the differential...??
  • 79. What is the differential...?? Drunk
  • 80. What is the differential...?? Drunk Stoned
  • 81. What is the differential...?? Drunk Stoned Drunk and stoned
  • 82. 911 CallCivilians standingat bus stop saypatient sitting onbench and “just fellover.”
  • 83. Behind door #2...
  • 84. Behind door #2...Pt. does not respondto painful stimuli,smells of alcohol,no obvious traumafound, put ongurney and carryinto rig and starttransport
  • 85. Behind door #2...Pt. does not respond En route, patientto painful stimuli, starts to havesmells of alcohol, seizures...no obvious traumafound, put ongurney and carryinto rig and starttransport
  • 86. Behind door #2...Pt. does not respond En route, patientto painful stimuli, starts to havesmells of alcohol, seizures...no obvious traumafound, put ongurney and carryinto rig and starttransport
  • 87. What do you do...?
  • 88. What do you do...?Benzo’sAirway supportEstablish ivGet to E.D.
  • 89. What do you do...?Benzo’sAirway supportEstablish ivGet to E.D.
  • 90. EMS History
  • 91. EMS History
  • 92. EMS HistoryDavid Rosenbaum, 2006Journalist living in D.C.Found by F.D. and thought to be intoxicatedEMS took 20 minutes to arrive & bypassed closesthospitalWaited in E.D. For an hour before RN notedpatient vomitingDied of trauma to head after assault
  • 93. Questions...?
  • 94. 911 Call35 year old malewith chest pain
  • 95. 911 Call35 year old malewith chest pain
  • 96. What is the differential...??
  • 97. What is the differential...?? Musculoskeletal
  • 98. What is the differential...?? Musculoskeletal Pulmonary
  • 99. What is the differential...?? Musculoskeletal Pulmonary Anxiety
  • 100. What is the differential...?? Musculoskeletal Pulmonary Anxiety Cardiac
  • 101. Behind door #3...States was going togym when feltpressure in middle ofchestGirlfriend made himcallHe thinks it’s just apulled muscle
  • 102. 911 Call
  • 103. 911 Call
  • 104. Now what...?MorphineOxygenNitroglycerinASACall to activate cathlab!!
  • 105. Normal Sinus
  • 106. Atrial Fibrillation
  • 107. Atrial Flutter
  • 108. Torsades de Pointes
  • 109. Ventricular Tachycardia
  • 110. Ventricular Fibrillation
  • 111. Medical Scenarios: Trauma Scenarios: Wrist Laceration Asthma Attack, Emphysema, Chronic Bronchitis, Burns CHF/Pulmonary Edema, Pneumonia, Pulmonary Skull Fracture Embolism Motor Vehicle Accident Myocardial Infarction (MI), Silent MI, Cardiogenic Diving Accident Shock, Abdominal Aortic Aneurysm, Syncopal Blunt Chest Trauma Episode Cardiac Tamponade Stroke, Transient Ischemic Attack, Grand Mal Seizure Penetrating Abdominal Trauma  Hypoglycemia, Diabetic Ketoacidosis, Hyperosmolar Upper Extremity Fracture Hyperglycemic Nonketotic Coma (HHNC) Femoral Shaft Fracture  Bee Allergy Joint Injury  Upper Gastrointestinal Bleed, Lower Gastrointestinal Vehicle vs. Pedestrian Accident Bleed, Appendicitis  Overdose  Heat Exhaustion  Ectopic Pregnancy, Placenta Abruptio, Placenta Previa, Normal Delivery, Nuchal Cord, Meconium Stain  Pediatrics—Croup, Pediatrics—Epiglottitis, Pediatrics —Asthma, Pediatrics—Bronchiolitis  Pediatrics—Hypovolemic Shock
  • 112. 911 Called - 58 yo female with allergicreaction
  • 113. On arrival, female complaining ofswelling of tongueStates has been getting worse allafternoonNow feels more difficulty speaking
  • 114. PMHx: HTN, HyperlipidemiaPSxHx: HysterectomyMeds: Lipitor, Niacin, LisinoprilAllergies: food allergies
  • 115. Went to Church this morning, attended aChurch picnic afterward, went home andtook a nap, awoke with swollen tongueVitals: HR 85, B/P 135/85, RR 16,Pulse Ox 96%
  • 116. Physical exam: well-nourished femalein NAD, PERRL, large tongue, no stridor,RRR, CTA bilat, soft/NT/+BS, no edema,MAE
  • 117. You suspect an allergic reaction. Namethree drugs that you would giveimmediately.
  • 118. Patient feels minimal improvement afteryou give the medication.
  • 119. You place on monitor in the ambulanceand pulse ox is now 91%. RR is 16.You would: A. do nothing B. start nasal cannula at 3L C. start face mask at 15L
  • 120. After applying oxygen, patient feelsslightly better but then begins tocomplain of chest pain. You look at themonitor and see sinus tachycardia. HR110.Why would she have this?
  • 121. You hang a bag of normal saline andstart to secure the patient when shesays, “I don’t feel so good” in a veryscratchy voice. She then stopsbreathing.
  • 122. For RSI name a drug that is an induction agent name a drug that is a paralytic
  • 123. Put these in order A. induction agent B. visualize vocal cords C. preoxygenate D. paralytic agent E. intubate
  • 124. Name 4 things that confirm ETTplacement
  • 125. Patient is successfully intubated
  • 126. You go to revital patient and see this onthe monitor, B/P 120/ 45Name a drug you can give for thisrhythm
  • 127. While you are deciding which drug togive, you start to see this on themonitor; there is no pulse
  • 128. What do you do now?
  • 129. If rhythm continues what do you donext?
  • 130. You get back a rhythm but then losepulses and see asystole on the monitor.What is the first thing you do?Name two drugs you would use
  • 131. You have return of spontaneouscirculation. Depending on protocol,what might you initiate?
  • 132. The patient is stable, HR 75, B/P130/50, intubated, 100% on pulse ox.Transport to E.D.
  • 133. Questions...??