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2010 CBT Workshop

2010 CBT Workshop. Agenda. ROC on Dr. Eisenberg Steve Perry Administrivia CPR Highlights Lowlights Application of skills. The ROCK. Any Changes? ROCKING on or off? Rock is still alive and well Analyze early and late and ITD are done Oct 2009 1600 enrolled

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2010 CBT Workshop

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  1. 2010 CBT Workshop

  2. Agenda • ROC on • Dr. Eisenberg • Steve Perry • Administrivia • CPR • Highlights • Lowlights • Application of skills

  3. The ROCK • Any Changes? • ROCKING on or off? • Rock is still alive and well • Analyze early and late and ITD are done Oct 2009 • 1600 enrolled • 94% cases correctly enrolled with AE/AL and ITD • 89 % correctly enrolled with ITD

  4. The ROCK • Receiving downloads fast then ever following HOT CALLS • Don’t Forget: • EMS witnessed • Every time compressions are started on a non traumatic patient • Cardiac arrest after Medics arrive • You’ve done such a good job****** • More to come

  5. CBT 2010 Mickey Eisenberg, MD Medical Director King County EMS

  6. Topics • Eisenberg’s Pet Peeves • Review of cardiac arrest survival • ROC trial summary • CPR protocol changes • DART trial summary • New MIRF for 2010 • Emphasis for 2010 • Revision in Protocol Book (Blue Book)

  7. Pet Peeves • Pulse oximeter is not a pulse detector. The old fashioned way to feel a pulse is the ONLY way to feel a pulse • A seizure may be the first sign of cardiac arrest. Do not use oxygen saturation to verify cardiac arrest • Glucose level must be documented after therapy • Remember IOS and MOI when using sick/not sick

  8. Survival from Witnessed VF Cardiac Arrest Update

  9. ROC Trial Update • NIH has stopped ROC-PRIMED and ITD because of similar survival in all arms of the study. • NO harm identified • Revision in King County CPR protocol in light of ROC Trial

  10. Changes in CPR Protocol Assess ABCs. Assess ABCs. If not breathing, open airway and provide two ventilations. If no pulse, perform chest compression while attaching defibrillator. Give verbal report and count compressions. When defibrillator is attached complete 30 compressions, clear patient, analyze rhythm, and shock if indicated. Always provide 30 compressions prior to any rhythm analysis. Subsequent CPR intervals should begin and end with 30 chest compressions and each interval should be 2 minutes (or slightly longer depending when 30 compressions end). Exception:When the patient goes into VF while monitored or attached to an AEDa defibrillatory shock may be administered immediately.

  11. CPR Protocol • Essentially a slightly modified analyze early • Confirm need for CPR, open airway, look listen and feel, two ventilations, 30 chest compressions (during which AED is attached), analyze, shock, 30:2:30:2:30:2:30 (for approximately 2 minutes or slightly longer – start and end with 30 chest compressions), analyze, if no shock indicated check pulse, if shock indicated shock, 30:2 etc

  12. DART Trial Findings • Dispatch Assisted Resuscitation Trial • King County, Thurston County, London • Comparing chest compression only versus chest compression and mouth-to-mouth • No difference in survival between the two messages • Chest compression delivered earlier with chest compression only

  13. New MIRF Backer for 2010 • Every patient to receive backer • Only exceptions are DOA patients, patients that leave the scene, or AMA patients • Must complete the electronic record • Case will be left open until record is complete • Please verify phone and address

  14. Transported You are being transported to a medical facility for further medical care. You may be billed for this service.

  15. Low Blood Sugar Your fire department measured your blood sugar during your medical emergency. Before treatment, your blood sugar level was _________________. • If you are choosing to stay at home: • Eat a FULL MEAL NOW. • Contact your doctor before you take your next insulin dose. If you are unable to contact your doctor, reduce your next insulin dose by 25%. Keep trying to contact your doctor. • Check your blood sugar frequently for the next several hours. • DO NOT: stay alone or drive/operate dangerous machinery for the next six (6) hours • If your condition worsens or initial signs and symptoms return, CALL 911 IMMEDIATELY! Your low blood sugar was treated by the following method: □ No Treatment The EMTs gave no immediate treatment because_________________________ □ Oral Glucose _______ gm □ Other ____________________ After administration of glucose and/or prior to the departure of the EMS Team, your blood sugar level was ________________ .

  16. High Blood Pressure Your fire department took your blood pressure during your medical emergency. Your blood pressure was very high. Blood Pressure Categories Systolic Diastolic Hypertension Stage 2 160 100 Hypertension Stage 1 140 90 Pre- hypertension 120 80 Normal <120 <80 Your Reading High blood pressure can lead to life-threatening disease such as heart disease, stroke, or kidney failure. There are good treatments for lowering high blood pressure. You need to talk with a doctor. We recommend that you have your blood pressure checked again as soon as possible.

  17. Community Resources • The Crisis Clinic offers support services available to • everyone in King County. Their staff gives immediate, • confidential assistance for people in need of help. Language interpretation is available. • DIAL 2-1-1 • (available Monday thru Friday from 8 am to 6 pm) • Caregiver & Disability Resources • Domestic Violence • Emergency Shelter • Financial Assistance for Rent or Utilities • Food & Clothing • Health Care & Support Groups • Legal Help • DIAL (206) 461-3222 • (866) 427-4747 • (available 24 hours a day) • Emotional Crisis & Trauma • Suicide Prevention & Education • www.crisisclinic.org

  18. Heart Attack Warning Signs Call 9-1-1 if you have: Chest Discomfort Uncomfortable pressure, squeezing, fullness, or pain in the center of the chest that lasts more than a few minutes, or goes away and comes back. Discomfort in Other Areas of the Upper Body May be felt in one or both arms, the back, neck, jaw, or stomach. Shortness of Breath Often occurs with or before chest discomfort. Other Signs May include breaking out in a cold sweat, nausea, or lightheadedness. Stroke Warning Signs • Call 9-1-1 if you have: • Sudden numbness or weakness of the face, arm or leg, • especially on one side of the body • Sudden confusion, trouble speaking or understanding • Sudden trouble seeing in one or both eyes • Sudden trouble walking, dizziness, loss of balance or • coordination • Sudden severe headache with no known cause

  19. Emphasis for 2010 • Continued emphasis on 3 major conditions: • CA (we can achieve 50% survival for VF) • Code ACS (recognition, STEMI, determination of onset, aspirin, expedited scene time and transport to hospital by paramedics) • Code CVA (recognition, determination of onset, expedited scene time and transport to hospital by EMTs

  20. Code ACS • Recognition and expedited care • Provide aspirin • Determine time of onset • Emphasis on STEMI and early alerting of hospital • Expedited transport to hospital by paramedics

  21. Code CVA • FAST exam • Facial weakness • Arm weakness • Speech abnormality • Time last seen normal • Check glucose, should be >60 • Determine if patient is taking coumadin (Warfarin) • Time hospital alerted • Expedited transport to hospital by EMTs

  22. Revision in EMT Protocols(Blue Book) • Current version was issued in 2007 • Suggestions for updates and changes are welcome

  23. AFTERCARE Not Transproted Transported Low Blood Sugar High Blood Pressure Community Resources

  24. Stroke Patients in King County: 2008 • Type code 234: 2190 patients coded as CVA/TIA. (2.3% of all EMS calls) • 13% received ALS care at the scene • 16% required intubation, 42% required IV line • Transport • 87% transported by BLS (60% by private ambulance) • 7% ALS • 3% not transported • 2% POV

  25. Falls If you are 65 or older and fell at home, there are two programs in King County that can assist you in staying healthy, independent, and safe in your home. Please call for more information. • One Step Ahead • King County Emergency Medical Services • (206) 369-5817 • Individualized health evaluation in your home • Free for those who qualify • Home safety check • Installation of home safety devices • Harborview Fall Prevention Clinic • (206) 744-4191 • Individualized health evaluation at Harborview • Home safety suggestions • Medication review, balance and vision checks

  26. AFTERCARE Not Transported Transported Low Blood Sugar High Blood Pressure Falls Community Resources

  27. Comments? Questions?

  28. 2010 CBT Workshops De-Fibrillation Coordinator Steve Perry King County EMS Training Division

  29. 2010 CBT Workshop • AED / Defib Program Up-date • Quality Assurance

  30. AED / Defib Program Up-date Through June 2009 • 425 CPR Cases • 57 of those cases were bystander-witnessed arrest due to CAD • 28 had VF as initial rhythm • 49%

  31. AED / Defib Program Up-date • Where we are and what do we know?? • Compressions • Compressions • Compressions • The more time on the chest the better

  32. AED / Defib Program Up-date The more time on the chest the better!! • Minimize time for analysis • Minimize time from defibrillation –resuming chest compressions.

  33. AED / Defib Program Up-date • Practice makes perfect practice. • Audio Information is important. • Stay focused. • Review your own cases.

  34. AED / Defib Program Up-date Confirm cardiac arrest – turn on AED while performing CPR ID self, company, approx age of pt, witnessed or not, pad application, clearing to analyze. Proceed with 30:2 compression to ventilations in adults 15:2 x 2 in child SHOCK if indicated – immediately start 2 mins CPR If NO SHOCK - check pulse – immediately start 2 mins CPR

  35. AED / Defib Program Up-dates Prior to January 2005 our resuscitation rate was < 36%.... We are currently > 48%......

  36. Quality Assurance We’re all in this together

  37. Quality Assurance • We have a problem…. • No one wants to be that guy 

  38. QA: Why??? • CC of Angina & RA SaO2 = 99%. When asked why no oxygen was applied, the comment was: “You can’t get higher than 100% so what’s the point?” • Uncons/Unresp & snoring after being struck by a car and the most important thing was to get the patient’s tennis shoes off. • OD with RA SaO2 of 96%, uncons, & snoring. (We were told “No O2 until SaO2 is <95%” • Since when is checking cervical dialation within an EMT’s standard of care??

  39. QA: Why??? • “His pulse is 70 bpm…According to the pulse ox..That’s what it says, is 70” • CC of respiratory distress applied a NRB at 8 lpm because: ”That’s how we were taught” • Mistake a hypoxic sz (VF) for an ill diabetic determined to get a blood glucose reading. • Female with NO BP sitting on toilet awaiting a doppler from a second due medic unit (“white as rice paper”)

  40. Quality Assurance • Remember who we are here for and why. • Check our egos at the door • Bed side learning is optimal • Chances are similar issues are occurring in other agencies so let’s help one another out!

  41. Quality Assurance Establish Continuity ID Training Needs (We are here for you!) Improve Performance • EMTAC – EMT Advisory Committee. • Paramedic Instructor Group

  42. Quality Assurance • Non-punitive • Constructive • Informative • Feedback loop • Site visits

  43. Culture • The Fire Service 100 years of tradition unimpeded by progress • Progress - one retirement at a time • Competition • Ownership • Lead by example • Instructors as ambassadors • Care and Feeding

  44. Administrivia • State • County

  45. 2010 CBT Courses • 301 Soft Tissue • 435 Abdominal Discomfort • 443 Altered LOC • 537 Pediatric Emergencies • 165 Sick vs. Not Sick • 938 Street Medicine

  46. 2010 301 Soft Tissue • Care for burns? • Penetration to the box? • Care for Tensions Pnuemothorax • Treatment of contusions, abrasions, lacerations, avulsions and amputations

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