Lecture #9

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jessjohnson0617
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212409
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Lecture #9
Updated:
2013-04-16 14:55:08
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Pharmacology Respiratory Emergencies Cardiac Patient Assessment
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Thurston County EMT
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  1. What does the scene size up consist of in medical and trauma patients?
    • scene safety
    • BSI
    • MOI/NOI
    • number of pts
    • additional resources needed?
    • spinal immobilization needed?
  2. What does the primary assessment in medical and trauma patients consist of?
    • general impression (sick or not sick/chief complaint)
    • treat life threats
    • assess LOC (AVPU)
    • spinal immobilization
    • ABCs
    • prioritize pt's needs
    • identify priority pts
    • transportation decision
  3. What is the secondary assessment on a responsive medical patient?
    • OPQRST
    • SAMPLE
    • Differential diagnosis
    • baseline vitals
    • treatment as needed
  4. What is in the secondary assessment in an unresponsive medical patient?
    • rapid assessment (differential diagnosis)
    • baseline vitals
    • SAMPLE
    • treatment as needed
  5. What is in a detailed physical exam in a medical patient?
    • complete head to toe
    • assess posterior of body
    • reassess vitals
  6. What is in the ongoing assessment of a medical patient?
    • reassess mental status
    • maintain airway
    • monitor breathing
    • reassess pulse
    • monitor skin color and temperature
    • reassess vitals signs
    • repeat focused exam
    • check interventions
  7. What are the 5 steps for patient evaluation?
    • determine chief complaint
    • determine the organ system likely involved (consider cardio and respiratory one system)
    • generate differential diagnosis
    • perform physical assessment of that organ system
    • revise differential diagnosis as needed
  8. What are the three ways to judge an area of complaint?
    visualize palpate, and ausculate
  9. What does AEIOUTIPPS respresent for a patient with an altered LOC?
    • A=alcohol/acidosis
    • E=epilepsy/electrolytes/endocrine
    • I=insilin
    • O=overdose
    • U=under dose/uremia
    • T=trauma
    • I=infection
    • P=phycosis
    • P=pump/poison
    • S=stroke/shock
  10. What are the clues in a patient exam that lead you believe the injury is in the cardio/respiratory system?
    • LOC
    • skin
    • JVD
    • chest/lungs
    • pedal edema
    • compare BP of each arm
    • vitals
  11. What are the clues in a patient exam that lead you to believe that the injury is in the neurological system?
    • LOC (*don't forget to consider AEIOUTIPPS*)
    • skin
    • eyes
    • facial droop
    • distal pulses
    • hand grips
    • vitals
  12. What are the clues in a patient exam that lead you to believe that the injury is in the genitourinary system?
    • skin
    • abdomen
    • femoral pulses
    • distal pulses
    • vitals
  13. What are the clues that lead you to believe that the injury is in the gastrointestinal tract?
    • skin
    • abdomen
    • vitals
  14. When lung sounds in the setting of SOB in a medical or trauma pt that are different from side to side - list the findings vs rule outs.
    • decreased on one side = pneumothorax, hemothorax
    • coarse crackles on one side = pneumonia (with fever), other infections
    • wheezing = respiratory infection
  15. When lung sounds in the setting of SOB in a medical or trauma pt that
    are different from top to bottom - list the finding vs rule out.
    fine crackles in bases = CHF
  16. When lung sounds in the setting of SOB in a medical or trauma pt that
    are the same throughout - list the findings vs rule outs.
    • clear = pulmonary embolism, ACS
    • wheezing = asthma, COPD, anaphylaxis
  17. What does the secondary assessment in a trauma patient with significant MOI or altered LOC consist of?
    • continue in line stabilization
    • reconsider transport decision
    • reassess mental status
    • rapid secondary assessment (60sec head-to-toe, anterior and posterior)
    • baseline vitals
    • SAMPLE
    • treatment as needed
  18. What does the secondary assessment in a trauma patient with a non-significant MOI/patient is alert and oriented?
    • assess the injury site (modified secondary assessment)
    • baseline vitals
    • SAMPLE
    • treatment as needed
    • transportation decision
  19. What does the reassessment of a trauma patient consist of?
    • reassess all of the following:
    • general impression
    • mental status
    • airway
    • breathing (quality/rate)
    • pulse (quality/rate)
    • skin color, temp, condition, bleeding
    • pt priority
    • vitals
    • emergency care

    continue to monitor the pr
  20. If there is a change in a trauma patient, you should...
    • repeat primary/secondary assessment
    • provide appropriate emergency care
    • reassess vitals
    • continue to monitor pt
  21. When performing the rapid secondary assessment on a trauma patient, you should expose, inspect, palpate, and auscultate the following portions of the head
    • scalp and skull
    • face
    • ears
    • eyes/pupils
    • mouth
    • nose

    maintain in-line stabilization
  22. When performing the rapid secondary assessment on a trauma patient, you
    should expose, inspect, palpate, and auscultate the following portions
    of the neck
    • anterior and posterior
    • apply c-collar
  23. When performing the rapid secondary assessment on a trauma patient, you
    should expose, inspect, palpate, and auscultate the following portions
    of the chest
    • clavicles
    • anterior/ausculate
    • assess breathing
  24. When performing the rapid secondary assessment on a trauma patient, you
    should expose, inspect, palpate, and auscultate the following portions
    of the abdomen
    • anterior
    • 4 quadrants
  25. When performing the rapid secondary assessment on a trauma patient, you
    should expose, inspect, palpate, and auscultate the following portions
    of the pelvis
    • anterior - press gently upward and downward
    • assess femoral pulses as needed
  26. When performing the rapid secondary assessment on a trauma patient, you
    should expose, inspect, palpate, and auscultate the following portions
    of the extremities
    lower and upper extremity - PMS
  27. When performing the rapid secondary assessment on a trauma patient, you
    should expose, inspect, palpate, and auscultate the following portions
    of the posterior side of the body
    • maintain in-line stabilization
    • assess posterior thorax, lumbar, buttocks, and back of legs
  28. At the end of your rapid assessment of a trauma patient, you should
    backboard by rolling after assessing posterior

    or use scoop
  29. What are the 5 rights?
    • right patient
    • right medication
    • right dose
    • right route
    • right time
  30. What are the adequate breathing rates for adult, child, and infant?
    • adult: 12-20
    • child: 15-30
    • infant: 25-50
  31. What are the different kinds of noisy breathing?
    • crowing (whooping)
    • audible wheezing (could be on inspiration, expiration or both)
    • gurgling
    • snoring/sonorous
    • stridor (whistling)
  32. Define respiratory distress.
    a condition where breathing is difficult or not effective
  33. What is COPD?
    Chronic Obstructive Pulmonary Disease

    could be emphysema, chronic bronchitis, but not asthma since that is episodic
  34. Define emphysema
    destruction of the alveolar walls causing a decrease in surface area on the alveoli, which in turn causes a retention in CO2 because capillaries cannot function properly
  35. What would you find on the assessment of a patient with emphysema?
    • pursed lip breathing
    • difficulty breathing
    • pink complexion ("pink puffers") - b/c of CO2 retention
    • tachypnea
    • tachycardia
    • diaphoresis
    • tripod position
    • may be on home O2
  36. Define chronic bronchitis
    • persistent productive cough for 3 consecutive months, 2 years in a row
    • inflammation, swelling, and thickening of the bronchi and bronchioles with excessive mucous production
  37. What would you find in the assessment of a patient with chronic bronchitis?
    • typically overweight
    • chronic cyanotic complexion ("blue bloaters")
    • difficulty in breathing
    • productive chronic cough
    • coarse lung sounds (crackling)
    • wheezing
  38. Define Asthma
    an episodic inflammatory disease that causes air to get trapped in the alveoli from narrowing and mucous obstruction of the bronchi and bronchiole
  39. Define pneumonia
    common disease in the elderly and those with suppressed immune systems, it is an acute infectious disease affecting the alveoli that is caused by bacteria or a virus
  40. Define Acute Pulmonary Edema
    sudden onset of fluid in the lungs caused by swelling and leaking of capillaries into lungs causing the alveoli to drown
  41. Define Pulmonary Embolism
    blockage in lungs (fat, blood, or air bubble) obstructing blood flow.

    pts with high suspicion of index: recent surgery, long international flights, sedentary lifestyle, family history of blood clots, divers
  42. Define a spontaneous pneumothorax
    a sudden rupture of visceral lining that changes the pressure in the lungs causing one to collapse
  43. Define hyperventilation syndrome
    a respiratory disorder involving breathing too deeply or too rapidly causing the pt to blow off too much CO2
  44. Define Epiglottitis
    inflammation of the upper airway
  45. Define pertussis
    • "whooping cough"
    • a highly contagious bacterial disease that starts similar to a cold, leads to complications especially in young children because of a lack of O2/CO2 gas exchange
  46. Define cystic fibrosis
    hereditary disease diagnosed earlier in life characterized by abnormal transport of chloride and sodium across an epithelium, leading to thick, viscous secretions causing pulmonary failure
  47. What are the three things that you can use through an MDI spacer?
    • Albuterol
    • Proventil
    • Ventolin
  48. What is albuterol?
    a bronchodilator
  49. How much additional O2 can you give with a small volume nebulizer?
    6 lpm
  50. What are the components of blood and what do they do?
    • RBCs = carry O2, hemoglobin, glucose
    • WBCs = soldiers of the immune system
    • Plasma = carry everything else
    • Platelets = responsible for clotting
  51. Define CHF
    congestive heart failure: the inability of the heart to pump all of the blood that is presented to ut bu the venous system; may be L or R sided (L sided = pulmonary edema = more serious)
  52. Define aortic aneurism
    a weakening or ballooning of the artery wall that could rupture causing severe pain, massive internal hemorrhage, and potentially death
  53. Define aortic dissection
    occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta, forcing the layers apart
  54. Define arteriosclerosis
    thickening, hardening, and loss of elasticity of arterial walls resulting in impaired blood circulation
  55. Define Atherosclerosis
    a condition in which an artery wall thickens as a result of the accumulation of fatty materials
  56. Define Ischemia
    a restriction in blood supply to tissues, causing a shortage of oxygen (caused from vasoconstriction, thrombosis, or embolism)
  57. Define Acute Coronary Syndrome
    a term for the signs and symptoms that result from cardiac ischemia
  58. Define Angina Pectoris
    chest pain due to ischemia of the heart muscle, caused from a mismatch in the O2 required and the O2 available
  59. Define myocardial infarction
    death of cardiac tissue from O2 deprivation (ischemia)
  60. Signs and Symptoms of a Myocardial Infarction
    • chest discomfort - squeezing, dull, tightness, heaviness
    • discomfort may radiate
    • dysrhythmias, pulmonary edema
    • tachycardia or bradycardia
    • sudden death from VF
  61. Define Lumen
    hole inside artery wall that blood flows through
  62. What is a thrombus and how does it form?
    • a blood clot inside a blood vessel that obstructs blood flow
    • fat pushes so much on lumen that platelets form to prevent rupture and cause ischemia
  63. Treatment for ACS
    • the same treatment as for an MI
    • ABC's
    • O2 as indicated
    • OPQRST
    • aspirin per protocol
    • nitro per protocol
    • defib as necessary
  64. Treatment for an MI
    • the same treatment as for ACS
    • ABC's
    • O2 as indicated
    • OPQRST
    • aspirin per protocol
    • nitro per protocol
    • defib as necessary
  65. What are the possible causes of Angina
    • physical excercise
    • strong emotion
    • extremes of temperature
    • (all these things increase cardiac workload)
  66. What is the classic presentation of ACS?
    • AHA classic warning signs of cardiac ischemia:
    • pressure, fullness, squeezing, or pain in the center of the chest that lasts more than a few minutes
    • discomfort that spreads to the shoulders, neck or arms
    • chest discomfort with lightheadedness, fainting, sweating, nausea, or SOB
  67. What is an atypical presentation of ACS?
    • AHA less common warning signs of cardiac ischemia:
    • atypical chest, stomach, or abdominal pain - well-localized, described as sharp in nature, wrong location such as upper abdomen
    • unexplained nausea without vomiting or chest pain
    • lightheadedness (not vertigo) without chest pain
    • unexplained anxiety, weakness or fatigue
    • palpitations, cold sweat, or pallor

    All these symptoms may be more common in women, diabetic and elderly
  68. Treatment for Cardiac Ischemia
    • O2
    • position of comfort (semi-reclining)
    • loosen tight clothing
    • restrict pt's movement and exertion (lift pt to stretcher)
    • administer aspirin and assist with nitro per protocol
    • ALS eval required
    • transport immediately (if no ALS/ALS is too far)
  69. What are the pertinent negatives in a patient with cardiac ischemia?
    • previous episodes (does this feel the same as is did last time?)
    • associated symptoms - cough recently, productive cough, fever, chills
    • effects of treatment - use of nitro - any effect, was it "fresh"
    • risk factors - BP? smoker? cholesterol?
    • family history - any family members with cardiac history
  70. What are the indications for the use of aspirin?
    s/s of ACS
  71. What are the contraindications for the use of aspirin?
    • allergic to aspirin
    • pt took aspirin just prior to EMS arrival
  72. What is the suggested dosage  of aspirin?
    • 325 mg PO chewed (4 81mg children's chewable tablets)
    • not indicated for pediatric pts
  73. What class of drug is aspirin?
    • anti-platelet
    • non-narcotic analgesic
    • NSAID
    • antipyretic (fever reducer)
  74. Precautions or adverse reactions to aspirin?
    NOOOOPE, there are none
  75. What are the indications for the use of nitroglycerin?
    • chest discomfort from ACS
    • symptoms similar to previous cardiac event
  76. What are the contraindications to the use of nitroglycerin?
    • pts taking viagra, cialis, levitra in past 48 hrs
    • severe bradycardia (HR <50/mins)
    • tachycardia (HR>100/min)
    • BP less than 100 mmHg systolic)
  77. What are the precautions/adverse reactions to the use of nitroglycerin?
    hypotension, headache
  78. What is the suggested dosage for nitroglycerin?
    • adult: 0.4 q 3 mins until pain relief
    • pediatric: not indicated for pediatric patients
  79. Assist with nitroglycerin dose every ___ minutes until ____ symptoms have subsided or BP falls below ____ mmHg systolic
    • 3
    • ACS
    • 100
  80. Do not give pt a dose of nitroglycerin if pt has already taken dose within the last _______
    3 minutes
  81. How do you administer nitroglycerin?
    sublingual
  82. What class of drug is epinephrine?
    adrenergic
  83. What are the indications for the administration of Epinephrine?
    • pt is displaying s/s of anaphylaxis: respiratory distress or shock or difficulty swallowing (throat edema) and consents to treatment
    • Epi-Pen Jr. is indicated in pts less than 30 kg (66 pounds)
  84. What are the precautions/adverse reactions to epinephrine?
    • increased BP
    • tachycardia
    • may cause cardiac ischemia in the elderly or in pts with know coronary artery disease
  85. What is the suggested dosage for epinephrine?
    • adult: 0.3 epi-pen
    • pediatric: 0.15 epi-pen jr
  86. What are the other names for albuterol?
    • proventil
    • ventolin
  87. What are the indications for the use of albuterol?
    • treatment of moderate to severe bronchospasm
    • repeat treatments as needed for symptoms of respiratory distress
    • s/s of hyperkalemia
  88. What are the contraindications for the use of albuterol?
    none
  89. What are the precautions/adverse reactions of albuterol?
    arrhythmias, tachycardia, severe chest discomfort
  90. What are the suggested dosages for albuterol?
    • Adult: nebulized initial dose - 5 mg; repeat as needed; MDI via BiPAP - 0.5 puffs, repeat as necessary up to 20 puffs; Nebulized - 10 mg added to 1 ml of sterile saline (hyperkalemia dose)
    • Pediatric: nebulized - 2.5 mg in 2.5 ml of saline if less than 2 y/o; otherwise use adult dose
  91. If pt has home nebulizer machine and albuterol, the EMT may assist the pt with the use of the machine in place of an MDI with an additional  ___lpm of O2
    6
  92. What class of drug is O2?
    oxidizer
  93. What are the indications for the use of O2?
    pts with s/s of shock, respiratory distress, respiratory arrest
  94. What are the indications to begin ACS management?
    • any of the following s/s:
    • uncomfortable "pressure", "fullness", or "squeezing" or discomfort in the chest or neck that lasts more than a few minutes, or that goes away and comes back

    discomfort that radiates to shoulders, neck, or arms

    chest discomfort with lightheadedness, fainting, sweating, nausea or shortness of breath

    symptoms similar to previous cardiac event
  95. What are the contraindications for the use of an AED?
    meets the criteria for DIF
  96. What are the indications for the use of AED?
    pts 1 yr or older who have confirmed circulatory arrest
  97. If it is an unwitnessed cardiac arrest, what are your next two steps?
    • perfrom CPR for 2 minutes
    • then initiate defib protocol
  98. What are the ALS upgrades for chest pain/discomfort/heart problems?
    • pt presenting with typical or atypical symptoms of ACS
    • chest discomfort associated with use of street drugs
    • upper abdominal pain, age greater than 35
  99. What are the indications for an MDI assist?
    • patient has a prescribed MDI of albuterol, proventil, or ventalin and
    • SOB unrelieved by epinephrine for anaphylaxis or
    • pt exhibiting s/s of breathing difficulty presumed secondary to asthma or COPD
  100. What are the contraindications for an MDI assist?
    pt is in respiratory arrest
  101. What is the first step in the MDI assist procedure?
    ALS upgrade
  102. Who is at risk for an atypical MI?
    • women
    • elderly
    • diabetic
  103. What are the two rhythms does an AED shock?
    • V-tach
    • V-fib
  104. Explain the 60 cycle interference.
    electrical devices that interfere with what the AED is analyzing. ex: fish tank, reclining bed, etc (if it is within spitting distance, unplug it

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