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Integration of Revised Region X SOP’s

Integration of Revised Region X SOP’s. February 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212. Prepared by: Sharon Hopkins, RN, BSN, EMT-P Rev 2.29.12. Objectives. Upon successful completion of this module, the EMS provider will be able to:

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Integration of Revised Region X SOP’s

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  1. Integration of Revised Region X SOP’s February 2012 CE Condell Medical Center EMS System Site Code: 107200E -1212 Prepared by: Sharon Hopkins, RN, BSN, EMT-P Rev 2.29.12

  2. Objectives • Upon successful completion of this module, the EMS provider will be able to: • 1. Identify treatment protocols per current Region X SOP’s. • 2. Explain rationale for treatment based on assessment of the patient. • 3. Given a variety of scenarios, utilize the SOP’s to determine treatment indicated for the patient. • 4. Given a variety of EKG rhythms, identify the rhythm and discuss treatment. • 5. Successfully complete the post quiz with a score of 80% or better.

  3. Region X SOP’s • Region X SOP’s went into effect February 1, 2012 • This CE module will incorporate reinforcing the SOP’s by working in small groups • A scenario will be presented • Work as a small group using the SOP’s as a reference to determine appropriate treatment

  4. Case Scenario #1 • EMS is called to the scene for a 87 year-old male who “fell” • The patient is unconscious and “bystander” CPR is being performed • Patient didn’t “fall”; was helped to the ground • EMS arrives on the scene, the scene is safe • EMS approaches the patient who is lying on the ground, not moving

  5. Case Scenario #1 • Upon arrival EMS needs to reassess the patient for evidence of breathing and presence of a pulse • There is no pulse, continue CPR • What equipment will be required? • First piece of equipment to attach is the monitor • Identifying the rhythm drives care to be delivered • Need vascular access • Anticipate additional methods to further secure the airway beyond BVM

  6. Point of discussion… • How do you perform 1 and 2 man CPR on an adult? • 30:2 ratio compression to ventilations • Compressions at a rate of at least 100/ minute • Once advanced airway placed, ventilate once every 6-8 seconds • How often do you switch CPR compressors? • Every 2 minutes (after 5 cycles) • Getting tired, you get sloppy, technique suffers

  7. Case Scenario #1 • What is the rhythm (NO PULSE!!!)? • PEA • What interventions are required?

  8. Case Scenario #1 • CPR • Searching for causes (H’s and T’s) • Begin fluid challenge if breath sounds are clear • Epinephrine 1:10,000 1 mg IVP/IO • May repeat every 3-5 minutes • If return of spontaneous circulation, follow ROSC Hypothermia Induction

  9. Point of discussion… • What methods are used to secure an airway? • Positioning – easiest, quickest, least attempted • BVM • May need oro/nasopharyngeal support • Endotracheal tube (ETT) • Most secure method to protect the airway • King airway • If 2 failed attempts with ETT or difficult airway • Combitube • Limited situations

  10. Case Scenario #1 • SOP’s utilized - PEA • Emergency Cardiac Care, Universal Adult (pg 6) • Pulseless Electrical Activity, Adult (pg 10) • Ref: CPR Guidelines (pg 85) • Skill: Intraosseous Infusion, Adult (pg 78) • Ref: ROSC Hypothermia Induction (pg 88)

  11. Case Scenario #2 • EMS is called to the scene of a private residence for a 25 year-old female with abdominal pain • Upon arrival the patient is lying on the couch appearing uncomfortable, pale, with shallow breathing • Patient is hugging a bucket and has the dry heaves • Patient weighs 160 pounds

  12. Case Scenario #2 • What information is important to obtain during assessment for any patient with abdominal pain? • O – onset – what were they doing? • P – what provokes/palliates it (makes it better)? • Q – what is the quality in their own words? • R – does it radiate? If yes, where? • S – how severe on a scale of 0 10? • T- what time did is start? • Have you inspected the site and have you palpated the abdomen?

  13. Case Scenario #2 • What information is important to obtain for a female with complaints of abdominal pain? • Ask about the potential for pregnancy • When was the last menstrual period (LMP)? • Need to consider an ectopic pregnancy • Patient may not even be aware she is pregnant

  14. Case Scenario #2 • What care is to be provided to this patient after obtaining the history of illness and SAMPLE? • Pain scale with reassessment • If SpO2 >94% does not need oxygen • EKG monitor (not indicated) • Careful - some “abdominal problems” may be cardiac issues masking as abdominal • IV access for medication administration • Fentanyl 0.5 mcg/kg IVP/IN/IO for pain • Zofran 4 mg IVP over 30 seconds for nausea

  15. Point of discussion… • If the patient weight falls in between on the SOP scale, what dose is followed? • Safer to go to the lesser amount • Can always give more medications but can’t get it back if already delivered • Can always do the math calculation for a precise amount

  16. Point of discussion… • How fast can these medications be given? • Fentanyl over 2 minutes • Zofran over 30 seconds • What side effects may occur? • Fentanyl may cause respiratory depression and muscle rigidity if given fast • Zofran may cause involuntary movements; often see drowsiness especially in children; side effects are rare

  17. Point of discussion… • If respiratory depression occurs with Fentanyl, what action is needed? • Can use Narcan as a reversal agent • Fentanyl is a synthetic narcotic • Prepare to ventilate (bag) the patient one breath every 5-6 seconds

  18. Case Scenario #2 • SOP’s Utilized – Abdominal Pain • Routine Medical Care, Adult (pg 5) • Pain Management, Adult (pg 34) • Nausea Management, Adult (pg 34) • Ref: CPR Guidelines (pg 85)

  19. Case Scenario #3 • EMS responds to a call for a 83 year-old female who fell. On arrival, the patient is found to be lying on her side and states “I can’t move my legs.” • Patient is conscious and alert • Pain in her hip and thigh is 10/10 if she tries to move • Patient weighs 180 pounds

  20. Point of discussion… • What question is important to ask for any call involving a patient who has fallen? • WHY did the patient fall? • Syncope/dizziness? • Think medical problem (ie: cardiac, CVA) along with trauma • Tripped? • Think trauma • Document WHY the patient fell and include in the verbal report • Consider need for c-spine immobilization

  21. Case Scenario #3 • VS: 136/80; P – 60; R – 16; SpO2 98% • What needs to be included in an orthopedic assessment? • MOI (mechanism of injury) • Consider additional injuries (ie: C-spine) • Appearance – Any deformity? Change in color? • Distal CMS/PMS/SMV before/after splinting • All abbreviations in SOP dictionary • Pain scale • Reassessment/response to treatment/interventions

  22. Case Scenario #3 • How is pain addressed? • RICE • Rest, ice, compress, elevate • Fentanyl 0.5 mcg/kg IVP/IN/IO • May repeat same dose in 5 minutes • Question… • Are you likely to see cardiovascular changes (ie: drop in B/P) with Fentanyl? • Cardiovascular changes are NOT seen

  23. Case Scenario #3 • SOP’s Utilized – Orthopedic Call • Routine Medical Care, Adult (pg 5) • Pain Management, Adult (pg 34) • Region X Field Triage Criteria (pg 30) • Routine Trauma Care, Adult (pg 29) • Document methods used to assess the patient and if determined no need for spinal immobilization/spinal motion restriction, include that documentation • Remember to consider distracting injuries

  24. Case Scenario #4 • EMS is called for a 2 year-old male who is having a seizure • Dispatch reports child is unconscious and breathing • On arrival, child found lying limp in mother’s arms • Pale, respirations even, moaning, drooling • VS: P – 148; R 12; skin warm; withdraws to pain & eyelids flutter

  25. Case Scenario #4 • Parents state patient had been relatively healthy with a “bit of a runny nose” last few days but “not that sick” • Patient was put down for a nap • Parents heard thrashing and found patient with seizure activity

  26. Point of discussion… • What is the patient’s GCS? • E – 2 (flutter to pain) • V – 2 (moaning/incomprehensible words/sounds) • M – 4 (withdraws) • Total 8 • Immediate care necessary • BVM • 12 breaths/minute NOT normal for a 2 year-old • Normal respiratory rate for 2 year-old – 20-30 breaths/min • Deliver 1 breath every 3-5 seconds

  27. Case Scenario #4 • What interventions are necessary if patient begins to have a seizure that does not stop relatively quickly? • Versed 0.1mg/kg IN/IVP/IO • Titrated to control seizure • Max 10mg • May be repeated if seizure activity continues/reoccurs • Evaluate glucose level • Blood glucose level 94

  28. Point of discussion… • Do all patients with an altered level of consciousness need to have a glucose level checked? • YES!!! • What’s most likely causing this child’s seizures? • Febrile • Poisons/chemical exposure/accidental overdose • Head injury • Tumor

  29. Case Scenario #4 • SOP’s Utilized • Routine Medical/Trauma Care, Pediatric (pg 43) • Altered Mental Status, Pediatric (pg 55) • Seizures, Pediatric (pg 56) • Febrile Seizures (pg 56) • Ref: CPR Guidelines (pg 85) • Ref: Vital Signs, Pediatric Normal (pg 93)

  30. Case Scenario #5 • EMS is called to the scene for a 57 year-old female feeling “ill” • Patient is lying on the couch awake but sleepily answering questions • Pale, diaphoretic, feels lightheaded when sitting up • Hx: diabetic, hypertension, old CVA • VS: B/P 86/56; P – 42; R – 20; SpO2 99% • Weight – 200 pounds

  31. Case Scenario #5 • What’s the rhythm? • Sinus bradycardia

  32. Point of discussion… • What indicators are present if the patient is unstable due to the bradycardia? • Stable and unstable patients can BOTH be • Pale, diaphoretic, feel lightheaded • If unstable • Altered level of consciousness • First indicator to change • Hypotension is present • Last indicator to change after compensation is exhausted

  33. Case Scenario #5 • What care is being provided to the patient? • IV access • Monitor – Sinus bradycardia • Atropine 0.5 mg rapid IVP/IO • Prepare for transcutaneous pacing • If Atropine ineffective, administer Valium 2 mg IVP/IO over 2 minutes (reduce anxiety) • Begin pacing • Manage pain with Fentanyl 0.5 mcg/kg IVP/IN/IO

  34. Point of discussion… • Is oxygen indicated? • No respiratory distress • SpO2 >94% • But… • Lightheaded • Decreased perfusion • Could be argument for applying per nasal cannula and argument for withholding • A clinical decision based on assessment • If in doubt, contact Medical Control

  35. Point of discussion: • Where are the pads placed for the TCP? • Anterior (-) chest pad in apical area • Posterior (+) pad placed in mid upper back between spine and scapula • If the TCP was applied, what are the settings? • Rate 80/minute • Sensitivity to “auto” • mA – start at 0 and increase until capture

  36. Case Scenario #5 • Application of pacing pads • Anterior/anterior Or • Anterior/posterior

  37. Point of discussion… • Why are both Valium and Fentanyl being used if the TCP is applied and activated? • Valium takes the edge off, relaxes the patient • Longer acting than Versed, so less repeat doses may be needed • Fentanyl issued for pain control • Getting electrical current sent thru the body 80 times per minute

  38. Case Scenario #5 • SOP’s utilized – Adult Bradycardia & AV Blocks • Adult Routine Medical Care (pg 5) • Universal Adult Emergency Cardiac Care (pg 6) • Bradycardia and AV Block, Adult (pg 12) • Pain Management, Adult (pg 34) • Skill: Transcutaneous Pacing (pg 76)

  39. Case Scenario #6 • You are called to the scene for a 43 year-old patient with a “racing heart” • Patient is anxious, slightly agitated • States has been under a great deal of stress, little sleep, taking Red Bull drinks • Warm and dry, lung sounds clear • VS: B/P 126/78; P – 170; R – 20; SpO2 97%

  40. Case Scenario #6 • What is the patient’s rhythm? • SVT

  41. Point of discussion… • Is the patient stable or unstable? • What do you assess? • What makes someone unstable? • First change is altered level of consciousness • Last change is hypotension • When can the valsalva maneuver be performed? • Stable SVT • Stable rapid a fib/flutter (narrow complex)

  42. Point of discussion… • How does the “valsalva maneuver” work? • Breath holding against a closed glottis increases intrathoracic pressure • Venous return decreases • Cardiac output falls (CO = HR x stroke volume) • B/P falls • Initially heart rate increases to compensate • When the breath is let out, sudden rise in blood flow increases pressures • The parasympathetic system is triggered with a vagal response and the heart rate decreases • Valsalva maneuver held for 10 seconds

  43. Case Scenario #6 • Treatment stable SVT • Valsalva • Bear down for 10 seconds • Adenosine 6 mg rapid IVP followed immediately with 20 ml normal saline flush • If no response in 2 minutes • Adenosine 12 mg rapid IVP followed immediately with 20 ml normal saline flush • If no response in 2 minutes • Verapamil 5 mg SLOW IVP over 2 minutes • If no response in 15 minutes and B/P >90, repeat Verapamil

  44. Point of discussion… • What does the patient often complain about while receiving Adenosine? • Hot, flushed feeling in the neck • Feeling of chest pressure • Feeling of not catching your breath • Just warn your patient they may feel weird for just a few minutes • Have them inform you if they feel weird

  45. Point of discussion… • What do you remember about Verapamil? • Inhibits movement of calcium movement • Will decrease the heart rate, contractility, and conduction • Causes vasodilation • Onset 1-2 minutes; duration 10-20 minutes • Avoid use in any bradycardia and history of WPW • Watch for hypotension and bradycardia

  46. Point of discussion… • What’s WPW (Wolff-Parkinson-White)? • Occurs in approximately 3/1000 persons • Abnormal conduction from atria to ventricles • AV node is bypassed • Characterized by short PR interval (<0.12 seconds), long QRS, slurred upstroke of QRS (delta wave) • EKG observation made when heart rate normal • Patient typically asymptomatic until tachydysrhythmias occur • Symptomatic due to increased heart rate

  47. Wolff Parkinson White • If rapid atrial fib with history of WPW, contact Medical Control • Amiodarone or cardioversion most likely to be ordered • Adenosine and Verapamil to be avoided

  48. Case Scenario #6 • SOP’s utilized – Adult SVT • Adult Routine Medical Care (pg 5) • Universal Adult Emergency Cardiac Care (pg 6) • Supraventricular Tachycardia, Adult (pg 15)

  49. Case Scenario #7 • EMS is called to the scene for a 69 year-old patient who is “sick” • Spouse states patient had not been acting right the past hour • Upon arrival, EMS notices patient slouched in a chair with mumbling speech • Denies chest pain or SOB • VS: B/P 120/60; P – 92; R – 18; SpO2 97%

  50. Point of discussion… • Are you thinking stroke? • What assessments are necessary? • Blood glucose level • Cincinnati stroke scale • Facial droop • Arm drift • Speech • Noting time of onset • Last known time to be normal

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