PATI 5400

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PATI 5400
2011-12-13 03:28:28

Advanced Care Paramedic Patient Management
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  1. Factors to Critical Thinking and Decisions:
    • What you were taught
    • Done and seen before
    • Believe to be right and true
    • People you work with
    • Employer Expectations
    • Medical director expects
    • Medical directives
    • Impression patient makes
    • Physical evidence
    • Receiving hospital expectations
  2. Critical Thinking:
    • Evidence based decision making
    • Application into practice
    • Self awareness
    • Reflective practice
  3. Critical Thinking Process:
    Concept formation, data interpretation, application of principle, evaluation, reflection on action
  4. Critical thinking Techniques
    • Role playing
    • Review
    • Reflection
    • Research
    • Consultation
  5. Evidence Gathering and Decision Making
    • Requires evidence
    • Know when you have enough for a decision
    • Need to re-direct evidence collection and assessment based on findings
    • History taking should provide structure to physical assessment and vice versa
  6. Primary decision
    • Life threats
    • ABC's
    • Priority management
    • Transport priority
    • How much help do you need? Allied agencies
    • When are you over your head?
  7. Evidence gathering
    • How sick is the patient?
    • How emergent is the patient?
    • Intervene now or after?
    • Which interventions are needed?
  8. History Taking
    • Chief complaint: level of distress, general impression
    • Incident history: onset, provocation/palliation, quality, region/radiation/referral, severity, time factor
    • Past medical history: including dates
    • Medication: drug, dose, regimen, compliance, prescription and non-prescription
    • Allergies
    • Last oral intake
  9. Physical Assessment
    • Neurologic
    • Respiratory
    • Cardiovascular
    • Musculoskeletal
    • Gastrointestinal
    • Genitourinary
    • Endocrine
    • Integuementary
    • Immune
  10. Physical Assessment Systems
    • Head and neck
    • Chest
    • Abdomen
    • Pelvis
    • Extremities
    • Back
  11. Respiratory Emergency
    • Primary Assessment
    • General Impression
    • Airway Sounds
    • Chief complaint
    • Primary Decisions
    • Assessment
    • Risk Factors
    • Medical History
    • Medications
    • History
    • Common Symptoms
  12. History
    • How long
    • Onset, what came first?
    • SOBOE (on exertion?) At rest? Positional?
    • Cough? Productive?
    • Sleeping position?
    • Other S+S
    • Meds use? Puffers? When? Did they work?
  13. Common Symptoms
    • Cough
    • Expectoration
    • Hemoptysis
    • Dyspnea
    • Chest pain
    • Wheezing
  14. Cough

    • Cough
    • -present
    • -strength
    • -chronic vs acute
    • -productive vs non productive

    • Expectoration (cough out from respiratory tract)
    • -Content
    • -Quantity
    • -Appearance
    • -Consistancy
    • -Odour
  15. Physical Assessment
    • Initial Impression
    • -posture and body position (posture, tripod, sitting, laboured breathing)
    • -face (speaking)
    • -surroundings (able to care for themselves)
    • -skin colour

    • Focused examination
    • -head and neck
    • -chest
    • -abdomen
    • -extremities
  16. Head and Neck Assessment
    • Flaring
    • colour
    • speaking ability
    • distractibility
    • tracheal position
    • JVD
    • tracheostomy
  17. Adventitious Breath Sounds
    • Wheezes (high and low pitch)
    • Crackles (coarse or fine; wet or dry)
  18. Wheezes
    • High - passage of air through narrowed bronchi; swelling bronchospasm, foreign body or growth, continuous musical whistling noise.
    • Low - air through secretions, continuous, low pitch
    • Mechanism - rapid airflow through obstructed A/W by bronchospasm, mucousal edema
    • Causes: asthma, CHF
  19. Crackles
    • Fine: clicking or popping, brief and explosive, usually on inspiration, produced when small airways pop open. Pneumonia, CHF, pulmonary fibrosis
    • Course: lower pitch coarse popping and bubbling sounds, inspiration and expiration. Larger airways cleared with coughing, pulmonary edema, retained, secretions
    • Mechanisms: excess A/W secretions moving with airflow
    • Causes: CHF, pulmonary edema, opening of collapsed airways, respiratory infections
  20. Ronchi
    • Low-pitched most often during expiration
    • Mechanisms: rapid airflow through obstructed A/W by excess sputum, bronchospasm
    • Causes: bronchitis, asthma
  21. Pleural Friction Rub
    • Moves jerkily/delayed by increased friction when inflamed
    • Vibrations produce a creaking sound
    • May sound like crackles
  22. Cyanosis
    • Poor oxygenation
    • Peripheral cyanosis (poor peripheral circulation)
    • Central cyanosis (poor systemic oxygenation)
  23. Pulse oximetry
    • Oxyhemoglobin to extremities
    • Limitations: poor perfusion, CO poisoning
  24. End Tidal CO2
    • Sampling and reference cell
    • CO2 is 35-45 mmHg
  25. Cardiovascular System Assessment
    • Primary (Environment, ABC's, Auscultation)
    • Primary Decisions (CC, Priority Management, Load & Go, oxygen therapy, back up allied)
    • History (focus on immediately need to know for treatment verses what can wait (clinical picure)
    • Assess Head and neck -LOA, JVD, cyanosis, expression, breath sounds, chest - inspection - symmetry, indrawing, scars, CLAPS; palpation integrity, TICS; abdo - pulsating masses and general appearance, pain, tenderness, distension, ascites; extremities - dependant edema, pulses and pulse variation, colour, temperature, capillary refill.
    • Medical History: PMHx, medications, allergies
  26. CP Causes
    • Cardiovascular (ACS, pericarditis, thoracic dissection)
    • Respiratory (pulmonary embolism, pneumothorax, pneumonia, pleural irritation)
    • Gastrointestinal (cholecystitis, pancreatitis, etc)
    • Musculoskeletal (costochondritis, trauma, tumors)
  27. ACS
    • Sudden ischemia, undifferentiated in first few hours
    • Angina, unstable angina, and myocardial infarction
    • Central anterior chest pain, dull, fullness, pressure, tightness, crushing pain, radiates, onset at rest.
    • Usual history only applies to males 55-75 y/o.
    • Atypical is fair game.
  28. Dysrhythmias Management
    • Decision Making
    • symptomatic vs asymptomatic
    • stable vs unstable
    • treat rate problems first
    • live better electrically
  29. Sinus Bradycardia
    • usually time limited, rarely pathologic
    • stable management: atropine, dopamine
    • unstable management: pacing
  30. Third degree block (includes second degree type II block)
    • almost always pathologic
    • straight to pacing
    • atropine etc. can make it worse
  31. Tachycardia
    • SVT, PSVT
    • Rarely pathologic, palpitations,
    • Stable management: adenosine, ACLS: verapamil, diltiazem
    • Unstable management: cardioversion
  32. Atrial Fibrillation
    • Controlled vs uncontrolled
    • rate vs embolus
    • 24 hour rule
    • Stable management: ACLS - amiodarone, procainamide
    • Unstable management: cardioversion, extreme caution due to risk, generally more difficult to cardiovert
  33. Ventricular Tachycardia
    • always pathologic
    • amio, lido, cardiovert
  34. Cardiac Arrest Management
    • CPR First
    • Rule out reversible causes (statistically patient has a better chance of survival if cardiac arrest is the result of a reversible cause that is identified and reversed
  35. Causes of Cardiac Arrest
    • 5H's and 5T's
    • Hypovolemia
    • Hypoxia
    • Hypothermia
    • Hypo/hyperkalemia
    • Hydrogen ions (acidosis)
    • Tamponade
    • Tension pneumothorax
    • Thrombosis (pulmonary embolus)
    • Thrombosis (ACS)
    • Tablets/Toxins, OD
  36. Time Sensitive Model
    • <4 minutes (electrical phase) - responds to electrical stimulation
    • 4-10 minutes (circulatory phase) - increased acidosis, CPR first
    • >10 minutes (metabolic phase) - too far gone for conventional therapies
  37. V-Fib, V-Tach
    • V-fib: chaotic, bizarre, disorganized electrical activity. No recognizable QRS. Coarse or fine.
    • V-Tach: wide, fast rhythm (>180) with out pulse
    • Management: R/O reversible causes, defibrillation, no supportive research for drugs, vasopressor (epi), antiarrhythmica (amio, lido)
  38. Asystole, PEA
    • Asystole: no electrical activity
    • Management: R/O reversible causes, assumption that rhythm is autonomic imbalance, supportive pacing if caught early.
    • PEA: electrical mechanical dissociation; should generate a pulse but doesn't.
    • Management: R/O reversible causes, directives give you something to do while you think (Fluid - hypovolemia; Epi - MI; Ventilation/Intubation - Hypoxia)
  39. Formulating A Management Plan
    • Primary Assessment/Management
    • -attending to immediate life threats
    • -airway, breathing, circulation
    • -transport priority
    • -how much help do you need?
    • -when are you over your head?
    • -priority managements

    • Evidence
    • -History (incident, past medical history)
    • -Physical assessment and complete vital signs (enough info to make the decision)

    • Decisions
    • -pt needs what?
    • -can I provide care? (Yes - scope of practice, directives, BHP; No - transport)
    • -when will I be over my head (ideal time to transfer care)

    • Ongoing decisions
    • -assessment and history gatherin to complete the clinical picture
    • -new decision based on additional information and evidence; patient response to treatment
    • -change in clinical presentation implies reassessment and a new management plan
  40. Acute Coronoary Syndromes Management
    • Decision Making - not a question of ruling in or out, but a question of risk.
    • General Management Decisions (treat rate first, assess and treat simultaneously)
    • Nitroglycerine - venous and coronary artery dilator
    • ASA - platelet aggregating inhibitor
    • Analgesia - morphine still the standard, vasoactive effects
    • Diagnosis - 12 lead
    • Transport
  41. Anaphylaxis Management
    • Airway management
    • Epinephrine (alpha and beta effects; provides some stabilization of MAST cells membrane, still only supportive care)
    • Benadryl (diphenhydramine - anti-histamine inhibits smooth muscle constriction and reduces capillary permeability)
    • Transport
  42. Diabetic Emergencies Management
    • Hyperglycemic Emergencies (HHNKs, DKA)
    • Hypoglycemic Emergencies (rarely occurs outside of diabetes)
    • Management: Addressing the symptoms
    • -Oxygen vs ventilation
    • -Fluid resuscitation
    • -Monitor for Acidosis
    • -Dextrose vs Glucagon
    • -Require follow up
  43. Heart Failure Management - Left Sided Backward Failure
    • oxygen
    • preload reduction (morphine, nitro, lasix)
    • treat complications
    • afterload reductions (ACE inhibitors)
    • worse case - intubate (preferred CPAP)
  44. Heart Failure Management - Cardiogenic Shock
    • General: forward failure, inability of the heart to meet the bodys metabolic needs, often remains after correction of other problems, severe form of pump failure, high mortality rate.
    • Causes: MI (impaired contractility), impaired ventricular emptuomg. dusrjutj,oas. tension pneumothorax and cardiac tamponade, trauma
    • Management: transport, treat the cause, and vasopressors (dopamine)
  45. Neurological Assessment
    • Primary Survey
    • Physical Exam: (pt hx, incident hx, VS, physical assessment)
    • Physical Findings: (distal strength, sensation, mobility, gait, balance, posture)
    • History: (Event, LOC, consider LOC as result of intracranial bleed)
    • Vital Signs: ICP (Cushings Triad)
    • Neurological Evaluation: (AVPU, GCS, Orientation, Memory, Response to stimuli)
  46. Amnesia
    • A pathologic impairment of memory
    • May be transient
    • Anterograde amnesia (for events after incident)
    • Retrograde amnesia (events before the incident)
  47. Decorticate Rigidity
    • abnormal flexor responses of one or both arms with extension of the legs
    • result from structural impairment of certain cortical regions of the brain
  48. Decerebrate Rigidity
    • abnormal extensor response of arms with extension of the legs
    • worse prognosis than decorticate rigidity
    • result from impairment of certain subcortical regions of the brain
  49. Conjugate Gaze
    Disconjugate Gaze
    Disconjugate Gaze: failure of the eyes to turn together in the same direction

  50. Coma
    • Abnormally deep state of unconsciousness from which the patient cannot be aroused by external stimuli
    • Two catagories - structural, metabolic
    • Causes: Acidosis or alcohol, Epilepsy, Infection, Overdose, Uremia, Trauma, Insulin, Psychosis, Stroke
  51. Neurological Emergencies Management: Stroke
    • General Management (airway, ventilations, oxygen, recognition, rapid transport, blood glucose testing and dextrose administration)
    • Comfort and support
    • Positioning: semmi-sitting, lateral if LOA decreases, affected size down if hemiplegia.
    • Treatments: A/W protection (increase ICP potential resistant to A/W maneuvers, difficulty clearing secretions/suctioning), Ventilations (effect on free oxygen radicals, controversies for hyperventilation)
    • Follow up: District stroke centres, CT Scan, Thrombolytic therapy, LTC - occupational and physical therapy, anti-platelet drugs, surgical interentions if appropriate, long term physio.
  52. Hyperventilation
    • Thought to reduce ICP by blowing off CO2 and reducing cerebral vasodilation
    • peak 30 minutes, diminishes of 1-3 hours
    • abrupt cessation of hypoventilation can cause rebound increased ICP
    • Moderate hyperventilation may have some effect but if underlying cause is not resolved then the ICP will continue
    • Anything more will likely cause cerebral vasospasm
    • Prolonged severe hyperventilation can worsen cerebral edema
  53. Seizure Management
    • Types: Grand mal, status epilepticus, casual factors, consequences
    • Assessment: head and neck (tongue bites, lips, stiff neck), Chest (decreased breath sounds, aspiration), GU (incontinence), Extremities (injuries from seizures)
    • Management: Protect pt, stop seizures. Oxygen as tolerated, manage byproduct injuries, manage underlying problem, pt privacy, blood sugar assessment, transport.
    • Long Term Management: Therapy to address underlying problem, no one drug controls seizures, phenytoin especially in children, most common cause of status seizure is non-compliance.
  54. Management Considerations in Environmental Emergencies
    • Extrication and transport is priority
    • Cannot get ahead of the underlying cause
    • Support management
    • Multi-system
    • High risk groups (elderly, very young)
    • Alcohol is most complicating factor (impaired thermogenesis, vasodilation, judgement, glucose stores)
  55. Environmental Cold Management
    • Extrication
    • Immobilization (risk of crystal formation and increased tissue trauma)
    • Prevention of further heat loss (strip off wet clothes, passive rewarming)
    • Gentle handling (risk of VF dramatically increases at CBT of 28 degrees C)
    • Weight the cost/benefits of anything else (A/W management, dysrhythmia management, fluid replacement)
  56. Drowning and Near Drowning
    • Extrication - consider diving injury possibility
    • A/W management - increased risk of aspiration and laryngo/bronchospasm, advanced management may become more of a priority
    • Hypothermia - lose more heat to water, complicating facor
  57. Environmental Heat
    • Extrication and transport remains priority
    • decreased LOA
    • A/W Management
    • Dehydration - responds well to crystalloid fluid administration
    • Heat Stroke - seizures to be expected, may/not respond to benzodiazepines, fluid replacement tends to be beneficial
  58. Pediatric Assessment
    • Environment
    • Initial assessment - pediatric assessment triangle (first impression), primary survey)
    • Secondary assessment - vital signs, focused history, physical examination
    • Ongoing assessment
  59. Pediatric Appearance Reflects the adequacy of
    • oxygenation
    • ventilation
    • brain perfusion
    • central nervous system function