A brief overview of the tolls we use in patient assessment. ETCO2 is a seperate presentation.

1. A N D H O W N O T T O G E T U S E D B Y T H E M … .
The Tools we use

2. RULE No. 1
 Tools supplement clinical thinking and details
subjective and objective assessments, they do not
replace them.
 AKA: Treat the patient, NOT THE MONITOR (or the
glucometer, or the pulse ox…)

3. RULE No. 2
 Tools fail if you:
 Don’t take care of them
 Don’t check them out EVERY SHIFT
 Don’t know how to use them
 Don’t know how to NOT use them
 Don’t read about the technology behind them…
 AKA: Murphy is a son of a bitch waiting to screw
with you and your equipment….

4. What we will cover…
 Stethoscope
 Sphygmomanometer
 Glucometer
 SPO2/SPCO
 EKG
 ETCO2

5. Stethoscope

6. Stethoscope
 Prior to the advent of the stethoscope, there were no
reliable, non-invasive (and therefore non-lethal)
methods to assess certain parts of the human
anatomy.

7.  A Stethoscope is used by Auscultation (listening)
 Sound is simply interpretation of vibrations by the specialized
nervous system structures that send data to the brain.
 Therefore any method that limits outside vibration and noise
will increase the fidelity of auscultation…
 Position to the patent
 Length and thickness of tubing on stethoscope
 Heels off ground in moving ambulance
 Environmental factors

8. Auscultation

9. Auscultation
1 1
2 2
3 3
A
4 4
5 5
6 6
H

10. Variations
 Electronic
 Recording
 Duo-stethascope (for
teaching)
 Fetoscope, AKA A Pinard
Horn

11. Sphygmomanometer
Rev. Stephen
Hale's
experiments to
determine the
blood pressure of
a horse.
Circa 1733

12. Sphygmomanometer
 When we talk about blood
pressure, we are usually
speaking of Non-Invasive
Blood Pressure (NIBP).
 This is used to estimate the
Mean Arterial Pressure
(MAP) and thus estimate
Aortic Pressure.

13. Key Point: Blood Pressure (NIBP) is an
indirect estimate of central perfusion
pressures

14. Blood Pressure (NIBP)
 Two basic types
 Manual
 Mercury
 Aneroid
 Automatic

15. Blood Pressure (NIBP)
 Systolic
 Diastolic
 Mm Hg
 Pulse pressure
 MAP

16. Blood Pressure
 Measure of pressure against SYSTEMIC vessel walls
 Systolic
 Pressure created in the arteries
 Reported first
 Diastolic
 Left ventricle relaxed and refilling
 Reported second

17. Pulse Pressure
 Generally speaking it is the pressure that produces a
pulse that we can feel.
 Specifically it is pulse pressure is calculated by
subtracting the diastolic pressure from the systolic
pressure.
 SBP – DPB = Pulse Pressure
 Significant for:
 A PP is considered LOW if it is less than 25% of the SBP.
 A narrowing PP is significant for progressing cardiac tapenade,
blood loss, or Tension Pneumothorax
 A high PP is significant for cardiac disease, HTN, and cor
pulmonale

18. Korotkoff Sounds in Blood Pressure
 Korotkoff sounds
 Sounds heard during auscultation of the blood pressure
 Caused by the jetting of blood through the collapsed artery.
 Systolic pressure: the first sounds as blood is pushed through an
artificially constricted artery covered by the BP cuff
 Diastolic pressure: the point at which blood flow is no longer
forced through the constricted artery (i.e pressure is no longer
great enough to collapse the artery).

19. Blood Pressure
 Stroke Volume (SV) x heart Rate (HR) = Cardiac
Output (CO)
 Cardiac Output (CO) x Systemic Vascular
Resistance (SVR) = Blood Pressure

 So B/P is the result of the “Pump” and the “Tank”,
and partly the “Volume”

20. Mean Arterial Pressure
 The MAP is an mathmatical estimate of the current
perfusion pressure.
 A minimum MAP of 50-60 mmHg is needed for most perfusion
sensitive organs.
Two main methods of calculation:
 Diastolic pressure + one third of the patients pulse
pressure:
 diastolic blood pressure + (pulse pressure/3).
 Diastolic pressure times 2 plus the systolic pressure and
then divide that number by 3:
 (diastolic pressure x 2) + systolic pressure] / 3
 “Normal MAP” is between 70—110 mmHg
 A normal MAP does not preclude a serious condition

21. Q: What is the 80-70-60 rule for blood
pressure?
Q: Is it accurate?

22. The 80-70-60 rule ?
 The minimum blood pressure predicted by the guidelines was
exceeded in only four of 20 patients.
 The mean blood pressure and reference range obtained for each
group indicate that the guidelines overestimate the systolic blood
pressure associated with the number of pulses present.

23. Orthostatic Blood Pressure
Procedure:
 Assess the need for orthostatics.
 Obtain patient’s pulse and blood pressure while supine.
 Have the patient sit up for one minute;
 Obtain the patient's blood pressure and pulse while
sitting.
 If positive orthostatic changes occur while sitting, DO NOT continue
to the standing position.
 Have patient stand for one minute.
 Free standing, not leaning.
 Obtain patient’s pulse and blood pressure while standing.
 Have someone stand on each side of the patient in case of orthostatic
syncope

24. Orthostatic Blood Pressure
 Orthostatics are considered POSITIVE if:
 The patient was unable to tolerate standing and became severely
symptomatic.
 If pulse has increased by 20 BPM OR systolic blood pressure
decreased by 20 mmHg, the orthostatics are considered positive.
 As an alternative, an increase of 10 BPM AND a decrease of 10
mmHg may also be considered positive if symptomatic.
 Document the time and vital signs for supine and
standing positions on/with the patient care report (PCR).
 KEY Points:
 You need both PULSE and BLOOD PRESSURE
 You need the patient to be in each position for a full minute.
 If they cant complete the test, it is considered positive.

25. Monitoring Blood Glucose
Source: Accu-Chek® Aviva used with permission of Roche Diagnostics.
Blood glucose monitoring kit

26. Monitoring Blood Glucose
 Perhaps the single most important factor in a
diabetics health is how well they monitor their own
BG.
 Severity of diabetic complications depends on
patient’s average blood glucose level.

27. Glucose Monitors Facts
 Personal use: Calibrated Monthly (rare)
 For EMS use: Calibrated WEEKLY
 Most have a chip which need to be changed with
EVRY BOTTLE OF NEW STRIPS
 Affected by temp
 Affected by time (samples must be applied w/in 30 –
60 seconds)

28. Blood Glucose Monitoring
 Should be done daily or more often.
 When done by EMS, should be done in the opposite
ext. as D50 was given.
 Venous blood usually runs about 10 mg/dl higher
than capillary blood.

29. Checking the Blood Glucose Level (BG)
 Glucometers are commonly found on EMS units.
 Determines the amount of glucose in the blood, the
sample usually coming from a finger stick.
 Glucose is measured in milligrams per deciliter
(mg/dl).
 A normal range is 80-120 mg/dl.
 Hypoglycemia is a BGL <60 mg/dl.
 Hyperglycemia is a BGL >150 mg/dl.
 Typically not significant until greater than 250. Often not
symptomatic until greater than 400 (not always true)

30. What are the numbers?
 Low: <60mg/dl (<3.0 mmol/L)
 Normal: 60-150mg/dl (3.0-8.0 mmol/L)
 Some recommend 120 mg/dl
 Hyperglycemic: >150 (>8.0 mmol/L)
 DKA usually seen at 250-500mg/dl

31. mmol/L vs. mg/dl
 What is an MMOL?
 It is a unit of measurement commonly used in
chemistry based on the molecular weight of the
substance it pertains to.
 To convert mmol/l of glucose to mg/dl, multiply by 18.
To convert mg/dl of glucose to mmol/l, divide by 18
or multiply by 0.055.

32. SPO2
 Pulse oximetry is a non-invasive method allowing
the monitoring of the saturation of a
patient's hemoglobin.
 Originally invented in the 1930’s, it expaded into Ors
in the 1980;s, and ER,s ICU’s, and EMS Units in the
early 1990’s. Early models were unreliable.
 Current technology is not only reliable, but leading
into other assessment parameters , including SPCO,
SPMet, and Fluid hydration status.
 There are still things that can “Spoof” common SPO2 devices.

33. SPO2
 It shines infrared light across the blood flow in the
capillary beds. The sensor then reads the light
reflected back. The color of the light is representative
of the state of the hemoglobin (hgb) that is bound up
with O2.
 Each hemoglobin molecule can be bound (carry) by
up to four oxygen molecules.
 The SPO2 is an expression of the percentage (%) of
hemoglobin that is bound.

34. SPO2
 SPO2 is always expressed as a percentage.
 By contrast, PAO2 (arterial pressure of oxygen) is
NOT expressed as a percentage.
 Even though the normal PAO2 is 80-100 mmhg it can be over
400 mmhg.

35. SPO2
 In Order to have a reliable reading, you must have:
 A good site to sample
 Adequate perfusion to that site
 Appropriate sensor
 A visible waveform to assess quality of reading

36. SPO2 Spoofs
 CO Poisoning
 Cyanide Poisoning
 Hypothermia
 Low perfusion states
 Shock
 Nail Polish
 High Light situations
 Poor Placement

37. KEY POINT
 Pulse oximetry measures solely hemoglobin
saturation, not ventilation, not perfusion, not
inspired FIO2, and not physiologic stress.
 SPO2 WORKS BEST when combined with other
monitoring tools, such as the EKG and especially
ETCO2

38. Hyperoxemia
 New discussions on the use of SPO2 to detect and
prevent hyperoxemia often “get it wrong”.
 Hyperoxemia is PAO2 in excess of 100 mmHg
 SPO2 parameters (controversial and debatable)
 94% SPO2 -> give O2
 94%-99% SPO2 -> give supplemental O2 only if in distress.
 99-100% SPO2-> consider withholding O2 or titrating down
O2 unless in severe failure

39. SPCO
 CO-Oxometry is the non-invasive measurement of
Carbon Monoxide (CO) in the capillary beds.
 It is a developmental evolution from SPO2
technology, originally designed for “low flow” states
in neonates.
 The current technology most commonly in use is the
RAD series from masimo.

40. The Rad Series

41. Benefits
 Uses “Signal Extraction technology” (AKA SET)
 This new generation can be potentially used for
SPO2, SPCO2, SpHg and SPMET.
 SET technology was originally developed to be a “low
perfusion state” and “Motion resistant” SPO2, whose
technology was expanded to CO-Oxometry
 Early device specific research papers focused on
neonates, alternative sensing locations, and
anesthesia settings.

42. RAD-57 Operation: Sensor Placement
 SENSOR
PLACEMENT IS
VERY IMPORTANT
 When possible, use ring
finger, non-dominant hand.
 Insert finger until the tip of
finger hits the STOP Block.
 Sensor should not rotate or
shift freely on finger.
 LED’s (red light) should pass
through mid-nail, not cuticle.
 There is a top and bottom,
cable should be on top
(nail side).
Optimal LED path

43. Carbon Monoxide: Suggested Triage Algorithm
Measure SpCO
0-3% >3%
No further medical
evaluation of SpCO
needed
Loss of consciousness or
neurological impairment
or SpCO >25%
Yes No
Transport on 100%
oxygen for ED
evaluation. Consider
transport to hospital
with hyperbaric
chamber
SpCO >12 SpCO <12
Transport on 100%
oxygen for ED evaluation
Symptoms of CO
exposure?
Transport on 100%
oxygen for ED evaluation
No further evaluation of
SpCO needed.
Determine source of CO
if nonsmoker
Yes No
SpCO TRIAGE
ALGORITHM

44. How its being used in EMS nationally
 Asymptomatic patients –
 Screening when there is a CO alarm, Hx of potential
exposure, or for rehab situations
 Asymptomatic Patients with elevated readings may be
screened and reevaluated after 15 minutes of High Flow
O2 and Medical Control Consult
 Asymptomatic patients without elevated levels may be
released on scene. (Controversial)
 Symptomatic patients
 Transport all symptomatic patients REGARDLESS OF
SPCO
 Screening for severity and diversion to HBO (Hyperbaric
therapy)

45. SPCO
 When used correctly : It is accurate within +/-2%
of carboxy-hemoglobin levels to measure CO (the
accepted standard)
 When not used correctly: It is useless and
provide false reassurance.

46. Downfalls
 Very sensitive, can be “spoofed” by strobes and high
ambient light.
 Cover the probe when “Zero”-ing to the patient
 Approx. $4,000 retail

47. Controversy
 There is some debate on the accuracy of the
technology.
 Operator error, high light environments, lack of understanding
of the technology all contribute to a high false positive and
false negative rate.
 Smokers, urban dwellers, and certain occupations have a
naturally elevated baseline. Their “Norm” may be in otherwise
“elevated CO” ranges.

48. W H E N W E G E T B A C K W E W I L L B E O N T H E
E T C O 2 P R E S E N T A T I O N … .
Take a Break