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Fall 2007 CME Presented by:

Fall 2007 CME Presented by:






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  • If we extrapolate these numbers for a one year time frame it amounts to an additional 27 extra lives saved per year. That is an amazing increase in survival from out of hospital cardiac arrest. These numbers only include patients that are in cardiac arrest due to a presumed cardiac event they do not include any other cause of arrest. The survival rate is derived from patients who present with an initial rhythm of VF or VT. Patients who are in asystole or PEA are not included in the survival rates. This data was made possible through our participation in ROC Epistry.
  • These symptoms are in addition to a symptom of chest fullness or discomfort or epigastric pain that does not sound like typical chest pain or heaviness that is the hallmark sign of acute myocardial infarct. For example, a patient who complains of epigastric pain but is non tender on palpation of the epigastric area with some fullness that is felt into the chest along with some of the symptoms above may be an atypical presentation of AMI.
  • The message here is that patients who have some sort of a chest pain or unusual feeling in their chest as well as some of the other symptoms listed on the previous slide should be given ASA, we are not asking paramedics to disregard the medical directive which states that there must be chest discomfort. We are mainly asking paramedics to do some critical thinking regarding the patient’s history as well as accompanying symptoms.
  • 1. Diabetic and post menopausal female 2. Onset: 30 minutes ago Provokes: pressing on the patient’s chest hurts Quality: chest ache, not really a pain just an ach or full feeling Radiation: does not radiate Severity: 3 or 4/10 Time: 40 minutes 3. Yes, this patient has some chest discomfort as well as other symptoms that might be related to cardiac ischemia. Deep palpation does increase the pain, if you press hard enough on anyone’s chest you will be able to cause or increase pain. 4. PCP’s should give high concentration oxygen, reduce cardiac work load by carrying the patient to the vehicle and transport to the closest ED. ACP and Level 2 in addition would start an IV and give NTG.
  • Epigastric pain that radiates into the chest and finds the epigastric area non-tender on palpation should always be treated as if it is cardiac until proven otherwise. Further history taking is advised with special attention to any GI problems such as ulcers or reflux disease, questions should also include bowel movement history specifically for the presence of black tarry stool or any frank blood to help rule out any GI bleeding. If the patient is clear for GI problems and other contraindications to ASA, then ASA would be appropriate.
  • Contraindications must be ruled out prior to administering ASA to all patients.
  • A 22 year old painter’s helper is carrying an open pail of paint thinner while he walks outside, to finish his cigarette. He stumbles and splashes thinner on his anterior chest and arms. The thinner bursts into flames and he suffers 2-3 rd degree burns to these areas, as well as 1-2 burns to his face. Co-workers quickly extinguish the flames and call 911. He is 10 minutes from the nearest hospital and 55 minutes to the Burn Centre.
  • First degree burns are painful red only. 2nd degree have blisters. Both 1-2 degree are painful!! 3rd degree is full thickness and is white or even black and is painless.
  • The most worrisome sign of an inhalation injury is hoarseness and stridor which suggest upper airway edema. Carbonaceous sputum, singed facial hair, burns to the face are associated with a greater risk of upper airway involvement, but are exterior to the airway.Swelling of the tongue is unusual as most patients close their mouths. Hypoxia can be causes by smoke inhalation alone,and asphyxiates such as CO which often kills people in fires before they burn. This is why people are found lying in floors near doors etc. MANAGEMENT OF THIS SITUATION. This patient is in pain and needs analgesics. You may be rightfully worried about the airway but it generally does not close immediately and you will not be able to adequately sedate him with your facilitated airway drug algorithm. Patching for more drugs in order to intubate him will only delay care. So What should you do?
  • Facilitating a patient like this is not an ideal way to manage the airway. If they are awake and struggling, your facilitated doses are to little. Patching and slowly sedating the patient to achieve intubation again does not provide the best intubating conditions. This should be a RAPID TRANSPORT TO THE NEAREST..This patient will not tolerate a mask as their face is burned. You can trial blow by 02, but sometimes even the blowing of 02 on their face hurts. 02 sat monitor can go on their toes IV can go on legs since not burned. The dorsum of the foot can be a painful place to start an IV. Consider the saphenous vein.
  • Alert them so they can prepare to do a rapid induction I.e. give 1 drug to render patient unconsciousness such as etomidate , and have fiber optic aids such as glidescopes or bronchoscopes
  • Blow by 02 can also be painful to someone with facial burns. If they are not hypoxic don’t push them, as their biggest concern is pain. IV in the saphenous. Suggest medics Google this to see where it is. Somewhat more tricky to cannulate than the dorsum of the foot but less painful. Can also give morphine SQ and IM. The IV is TKVO unless patient is hemodynamically unstable. Burns cause cells to be leaky, so don’t aggressively rehydrate until airway secured. The morphine requirements of these patients is substantial and standing orders are unlikely to cover it. When you patch for pain medication, the BHP will also be concerned about the airway…make sure you are en route to a hospital you have notified and clearly explain your plan.
  • If they are involved in a fire, and unconscious with little or no burns they are suffering from asphyxiation e.g. hypoxia due to CO , CN or other toxin in smoke. Always prepare downsized ETT, UNCUT and use oral approach in burn patients in order to visualize the anatomy,preserve diameter and length of ETT. Don’t use nasal if you can avoid it. Why?As facial swelling occurs with fluid administration, the ETT will be pushed out of the nares and hence trachea. Oral ETT Uncut has much more length, and this is a lower risk.

Fall 2007 CME Presented by: Fall 2007 CME Presented by: Presentation Transcript

  • Fall 2007 CME Presented by: SOCPC
    • Presentations:
    • Witnessed cardiac arrest – the importance of rapid defibrillation
    • Atypical chest pain presentations and ASA administration
    • Airway Management of the Burned Patient
    • Stations:
    • CVAD access, new IV tubing, safety syringe and D50W administration for Level II
    • Cardiac Arrest
    • Pediatric case presentations
    • Post Knowledge Assessment Tool
  • Toronto Cardiac Arrest Stats
    • May 2006 to October 2006: introduction of new AHA guidelines during Spring 2006 CME
    • Out of hospital cardiac arrest survival rate: 12.6% or 17 patients survived to discharge from hospital (cardiac caused VF arrest)
    • November 2006 to April 2007: new guidelines in fully implemented
    • Out of hospital cardiac arrest survival rate: 20.9% or 28 patients survived to discharge from hospital (cardiac caused VF arrest)
  • To Shock or Not to Shock That is the question!
  • Cardiac Arrest
    • 3 Phases
      • Phase One: Electrical from onset to 4 minutes
      • Phase Two: Circulatory from 4 minutes to about 10 minutes
      • Phase Three: Metabolic about 10 minutes after onset of arrest
  • Phase One: Electrical
    • From onset of arrest to about 4 minutes after arrest
    • Defibrillation has the greatest effect during this phase
    • Includes all Paramedic witnessed arrest patients
    • AED’s in casinos have a better then 70% success rate
  • Phase One: Electrical
    • Studies show a 10% drop in survival rate with each minute that defibrillation is delayed
    • In Paramedic witnessed arrest rapid defibrillation has a very high conversion rate
  • Phase Two: Circulatory
    • Patient has been in VF for at least 4 minutes
    • Many patients who are shocked in this phase prior to any CPR tend to go into a refractory asystole
    • Performance of CPR prior to shocking these patients drastically improves their chances of survival
  • Phase Three: Metabolic
    • In this phase patients need medications and other techniques to resuscitate them
    • Survival is generally poor 10 minutes post arrest
    • Induction of hypothermia in this phase may exhibit some improvement in survival rates
  • Paramedic Witnessed VF Arrest
    • In a Paramedic witnessed VF arrest the best chance for the patient to survive is to shock right away
    • The longer the delay the lower the survival rate
    • Some patients who are shocked without delay are conscious within a short time after arrest
  • Unwitnessed Cardiac Arrest
    • Any patient who is in cardiac arrest prior to paramedic arrival will have some CPR performed prior to defibrillation
    • CPR prior to defibrillation allows for circulation of blood and improves outcomes to defibrillation
    • Paramedic Witnessed VF Arrest = Shock right away
    • Unwitnessed Arrest = CPR prior to shock
  • Minor Change to Zoll Configuration For “Analyze Early”
    • Upon arrival at a cardiac arrest one paramedic will turn the Zoll on while the other paramedic begins up-front compression only CPR
    • CPR will continue until the defibrillator is ready to be hooked up to the patient
    • Once hooked up the Zoll will auto-analyze and auto-charge (if rhythm is shockable)
    • Once analysis has been completed and the shock has been delivered (if applicable) the medical directive will be continued as usual
  • Dextrose Administration for Level II Paramedics
    • Level II Paramedics will be able to administer D50W at the end today’s CME
    • Paramedics are reminded to review the hypoglycemia medical directive
    • Level II Paramedics are able to administer D50W in all crew configurations (LII/ACP, LII/PCP and LII/LII)
  • Medical Directive FAQ’s
  • Question 1
    • How many times should a PCP analyze a patient who initially arrests enroute to the hospital?
    • A PCP should perform 3 analysis prior to resuming transport
    • Note: 1 st analysis should be done ASAP and the 2 nd and 3 rd analysis should occur at 2 minute intervals
  • Question 2
    • When must an ACP attend to a patient en route to hospital?
    Answer Refer to handout (SOCPC-7 PCP/ACP Crew Configuration Division of Responsibilities) and review in its entirety
  • Question 3
    • Should an ACP administer cardiac arrest medications in a traumatic cardiac arrest patient?
    • Epinephrine and atropine have not been shown to have any benefit in the traumatic arrest.
    • If a paramedic is to administer these drugs in this setting they MUST be administered enroute to the hospital only.
    • A paramedic will not be questioned should these drugs not be delivered in a traumatic arrest.
    • Page 54: remove second 10mL/kg bolus
    • Page 55: 2 a 0.01 mg/kg = 0.1 ml/kg NOT 0.1 mg /kg
    • Page 61: Procedure # 6 systolic BP for pediatric pt should read < 40kg NOT ≥ 40kg
    • Page 67: FTT guidelines
    • Physiological Criteria
    • Should include under “any 2 of the following criteria”
    • Presenting GCS of < 14
    Corrections Version 1
  • Corrections Version 2
    • Page 89:
      • Lidocaine dosage in the Pediatric Cardiac Arrest Chart should be doubled for ETT route
      • Atropine dosages in the Pediatric Cardiac Arrest Chart should be disregarded as they are not part of the pediatric arrest protocol
  • Atypical Chest Pain
  • Symptoms of ACS
    • 70-90% of patients with cardiac ischemia have typical chest pain
    • BE CAREFUL! This means up to 30% of patients with cardiac ischemia don’t have typical chest pain.
    • High risk patients for atypical presentations are: diabetics, elderly and women
  • ASA Stats
    • ASA is the most under-administered medication that paramedics can give.
    • Up to 45% of patients with chest pain/discomfort, treated by paramedics, did not receive ASA.
    • Remember ASA and NTG are administered independently of each other. Some patients may get ASA, but not NTG.
    • Document reasons for not administering ASA
  • Other Symptoms of AMI
    • SOB
    • Agitation
    • Anxiety
    • Cyanosis
    • Diaphoresis
    • Nausea and vomiting
    • Palpitations
    • Sense of impending doom
  • Is ASA good?
    • ASA reduces mortality almost as much as thrombolytics
    • ASA should be given to all patients who do not have any contraindications who may be having cardiac ischemia
    • Absence of typical chest pain does not necessarily mean absence of cardiac ischemia
  • Case 1
    • 65 year old diabetic female complaining of shortness of breath, dizziness, sweatiness and has a mild chest ache that increases on palpation
    • Pulse: 104 f & r
    • Resp: 24 d & r
    • BP: 150/90
    • SPO 2 : 94 on room air
    • Cardiac monitor: shows sinus tach
  • Is it cardiac Ischemia?
    • What in the patient’s history would lead you to suspect a cardiac problem?
    • What else do you want to know about the patient?
    • Should this patient be given ASA if she has no contraindications?
    • What other treatments would you offer this patient?
  • Case 2
    • Call to an office building for a 50 year old female with epigastric pain
    • Pain does not change with palpation, radiates up into her chest but is not localized, feels like gas, patient is burping
    • Patient has history of high BP and high cholesterol
    • In the absence of contraindications should this patient be given ASA?
  • Case 2
    • This patient should be given ASA
    • ASA is a relatively benign drug in the absence of contraindications
    • The benefits of giving ASA far out weigh the risks even when the chest pain described is not clearly ischemic chest pain
  • Take Home Messages
    • Up to 30 % of diabetics, elderly and women experiencing cardiac ischemia may not have typical chest pain
    • Atypical cardiac ischemia in these high risk patients and other patients may present as SOB, weakness etc. on their own without the typical chest pain of MI
    • If you suspect cardiac ischemia in any patient who may be presenting without typical chest pain give ASA if there are no contraindications
  • Airway Management of the Burned Patient
  • Case
    • 22 yr old painter, trips while carrying a tray of paint thinner
    • He is 6’5” 100 kg.
    • It splashes up onto his, arms, and anterior chest
    • He is also smoking….
    • What do you think happened?
  • Sustained
    • 2-3rd burns to his arms including hands, anterior chest
    • Flames came up over his face and he has singed the hair on his face and top of head
    • His face is red with 1-2 blisters forming on his chin
    • What degree burn is on his face?
  • Airway
    • He is in extreme pain and wants some ()&(*^##!! Medication for the pain!!!
    • As he speaks he is hoarse and has slight stridor
    • What are the most worrisome signs of an inhalation injury to the airway?
    • How will you manage this situation?
  • The others A’s in Airway
    • Recognize the injury to the Airway
    • If they need definitive airway management but are too awake for you to provide it, even with facilitation
    • A- Accelerate to the nearest hospital
    • A - Alert them you are coming
  • A-Alert
    • Alert the hospital
    • They will get a team ready with:
    • IV Induction agents
    • Fibre-optic intubation equipment such as a glidescope and bronchoscope
    • All of which increases the chance of a successful intubation
  • How was this patient managed?
    • Rapid transport to the nearest hospital which was Alerted.
    • Blow by 02
    • While en route to hospital:
    • IV started in Saphenous vein (arms too burned). Just TKVO
    • Patched for increased Morphine for pain.
    • At hospital met by team ready to intubate
  • Which burn patients should you intubate in pre-hospital setting?
    • Unconscious
    • Near or in Respiratory Arrest
    • VSA