FCA 0811 - EMS Differential

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Redwood Memorial Hospital
EMS Field Care Audit Lecture

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FCA 0811 - EMS Differential

  1. 1. WHAT’S BEHIND DOOR NUMBER 2...? Veronica Bonales, M.D. CEPAmerica, Emergency Medicine EMCC Paramedic Coordinator
  2. 2. 911, What’s your emergency?
  3. 3. Responding to a Call
  4. 4. Responding to a CallNeed the info
  5. 5. Responding to a CallNeed the info Age
  6. 6. Responding to a CallNeed the info Age Sex
  7. 7. Responding to a CallNeed the info Age Sex Chief Complaint
  8. 8. What are the possibilities?
  9. 9. What are the possibilities?AKA the differential...
  10. 10. What are the possibilities?AKA the differential... What could cause chief complaint?
  11. 11. What are the possibilities?AKA the differential... What could cause chief complaint? What are issues related to age?
  12. 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. 13. Headache
  14. 14. Headache
  15. 15. Headache
  16. 16. HeadacheMigraine
  17. 17. HeadacheMigraine CVA
  18. 18. Headache Migraine CVABleed
  19. 19. Headache Migraine CVATrauma Bleed
  20. 20. Headache Migraine CVATrauma Infection Bleed
  21. 21. Headache Migraine CVA TumorTrauma Infection Bleed
  22. 22. Headache Migraine CVA TumorTrauma Infection Bleed
  23. 23. Headache Migraine CVA TumorTrauma Infection Bleed
  24. 24. Headache Migraine CVA TumorTrauma Infection X Bleed
  25. 25. Headache X Migraine CVA TumorTrauma Infection X Bleed
  26. 26. Headache X Migraine X CVA TumorTrauma Infection X Bleed
  27. 27. Chest Pain
  28. 28. Chest Pain AGE-related CAUSES - infant SEX - Muscle/Skeletal - child - Male - Cardiac - teen- Female - Pulmonary - adult - GI - elderly
  29. 29. Shortness of Breath
  30. 30. Shortness of Breath CAUSES- Muscle/Skeletal - Cardiac - Pulmonary - GI
  31. 31. Abdominal Pain
  32. 32. Abdominal Pain
  33. 33. Primum Non Nocere
  34. 34. Arriving at the Scene
  35. 35. Arriving at the SceneSurvey the sceneA - AirwayB - BreathingC - CirculationD - DisabilityE - Exposure
  36. 36. VitalsHeart RateRespiratory RateBlood PressureTemperaturePain Scale
  37. 37. Physical ExamFocused but thorough
  38. 38. Clinical Scenarios
  39. 39. 911 Call28 y.o. female c/oabdominal pain andvaginal bleeding.
  40. 40. 911 Call28 y.o. female c/oabdominal pain andvaginal bleeding.
  41. 41. What is the differential...??
  42. 42. What is the differential...?? Ectopic pregnancy
  43. 43. What is the differential...?? Ectopic pregnancy Ruptured ovarian cyst
  44. 44. What is the differential...?? Ectopic pregnancy Ruptured ovarian cyst Dysparunia
  45. 45. What is the differential...?? Ectopic pregnancy Ruptured ovarian cyst Dysparunia Complicated UTI
  46. 46. What is the differential...?? Ectopic pregnancy Ruptured ovarian cyst Dysparunia Complicated UTI Trauma
  47. 47. Behind door #1...Pain off and onsince last nightNow more intenseand more frequentcramping painNoticed blood afterwent to bathroom
  48. 48. Behind door #1...Pain off and onsince last nightNow more intenseand more frequentcramping painNoticed blood afterwent to bathroom
  49. 49. Now what...??
  50. 50. Now what...??Imminent delivery
  51. 51. Now what...??Imminent delivery Back-up
  52. 52. Now what...??Imminent delivery Back-up Supplies
  53. 53. Now what...??Imminent delivery Back-up Supplies Position
  54. 54. Now what...??Imminent delivery Back-up Supplies Position Slow and controlled
  55. 55. Now what...??
  56. 56. Now what...?? Not this.....
  57. 57. Now what...??
  58. 58. Now what...??Place patient into position
  59. 59. Now what...??Place patient into positionGloves or clean hands
  60. 60. Now what...??Place patient into positionGloves or clean handsTowel and control the head
  61. 61. Now what...??
  62. 62. Now what...??Support head
  63. 63. Now what...??Support headTell mother to stop pushingwhen head is out
  64. 64. Now what...??Support headTell mother to stop pushingwhen head is outCheck for nucal cord
  65. 65. Now what...??Support headTell mother to stop pushingwhen head is outCheck for nucal cordRemove if found
  66. 66. Now what...??
  67. 67. Now what...??Support head
  68. 68. Now what...??Support headPull down then pull up todeliver each shoulder
  69. 69. Now what...??Support headPull down then pull up todeliver each shoulderHold baby firm as will slideout easily
  70. 70. Now what...??
  71. 71. Now what...?? Protocols...
  72. 72. Now what...?? Protocols... Lay baby on mother’s abdomen and transport
  73. 73. Now what...?? Protocols... Lay baby on mother’s abdomen and transport Cut umbilical cord and transport
  74. 74. Now what...?? Protocols... Lay baby on mother’s abdomen and transport Cut umbilical cord and transport Deliver placenta and transport
  75. 75. Questions...?
  76. 76. 911 Call40 something yearold male witnessedfall at bus stop
  77. 77. 911 Call40 something yearold male witnessedfall at bus stop
  78. 78. What is the differential...??
  79. 79. What is the differential...?? Drunk
  80. 80. What is the differential...?? Drunk Stoned
  81. 81. What is the differential...?? Drunk Stoned Drunk and stoned
  82. 82. 911 CallCivilians standingat bus stop saypatient sitting onbench and “just fellover.”
  83. 83. Behind door #2...
  84. 84. Behind door #2...Pt. does not respondto painful stimuli,smells of alcohol,no obvious traumafound, put ongurney and carryinto rig and starttransport
  85. 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. 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. 87. What do you do...?
  88. 88. What do you do...?Benzo’sAirway supportEstablish ivGet to E.D.
  89. 89. What do you do...?Benzo’sAirway supportEstablish ivGet to E.D.
  90. 90. EMS History
  91. 91. EMS History
  92. 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. 93. Questions...?
  94. 94. 911 Call35 year old malewith chest pain
  95. 95. 911 Call35 year old malewith chest pain
  96. 96. What is the differential...??
  97. 97. What is the differential...?? Musculoskeletal
  98. 98. What is the differential...?? Musculoskeletal Pulmonary
  99. 99. What is the differential...?? Musculoskeletal Pulmonary Anxiety
  100. 100. What is the differential...?? Musculoskeletal Pulmonary Anxiety Cardiac
  101. 101. Behind door #3...States was going togym when feltpressure in middle ofchestGirlfriend made himcallHe thinks it’s just apulled muscle
  102. 102. 911 Call
  103. 103. 911 Call
  104. 104. Now what...?MorphineOxygenNitroglycerinASACall to activate cathlab!!
  105. 105. Normal Sinus
  106. 106. Atrial Fibrillation
  107. 107. Atrial Flutter
  108. 108. Torsades de Pointes
  109. 109. Ventricular Tachycardia
  110. 110. Ventricular Fibrillation
  111. 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. 112. 911 Called - 58 yo female with allergicreaction
  113. 113. On arrival, female complaining ofswelling of tongueStates has been getting worse allafternoonNow feels more difficulty speaking
  114. 114. PMHx: HTN, HyperlipidemiaPSxHx: HysterectomyMeds: Lipitor, Niacin, LisinoprilAllergies: food allergies
  115. 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. 116. Physical exam: well-nourished femalein NAD, PERRL, large tongue, no stridor,RRR, CTA bilat, soft/NT/+BS, no edema,MAE
  117. 117. You suspect an allergic reaction. Namethree drugs that you would giveimmediately.
  118. 118. Patient feels minimal improvement afteryou give the medication.
  119. 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. 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. 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. 122. For RSI name a drug that is an induction agent name a drug that is a paralytic
  123. 123. Put these in order A. induction agent B. visualize vocal cords C. preoxygenate D. paralytic agent E. intubate
  124. 124. Name 4 things that confirm ETTplacement
  125. 125. Patient is successfully intubated
  126. 126. You go to revital patient and see this onthe monitor, B/P 120/ 45Name a drug you can give for thisrhythm
  127. 127. While you are deciding which drug togive, you start to see this on themonitor; there is no pulse
  128. 128. What do you do now?
  129. 129. If rhythm continues what do you donext?
  130. 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. 131. You have return of spontaneouscirculation. Depending on protocol,what might you initiate?
  132. 132. The patient is stable, HR 75, B/P130/50, intubated, 100% on pulse ox.Transport to E.D.
  133. 133. Questions...??

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