DOT National Standard EMT-Intermediate/85 Refresher

1. Welcome! DOT National Standard EMT-Intermediate/85 Refresher

2. Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease ■ Provide ventilatory support for a patient ■Attempt to resuscitate a patient in cardiac arrest ■ Provide care to a patient experiencing cardiovascular compromise ■Provide post resuscitation care to a cardiac arrest patient MEDICAL EMERGENCIES

3. Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx MEDICAL EMERGENCIES

4. Do not start CPR • Documented pulseless & nonbreathing for more than 15 min by a reliable witness who has observed the pt carefully • Pulseless & nonbreathing w/ signs of prolonged lifelessness (e.g. rigor mortis, lividity) • Burns or decapitation

5. Note: downtime for initiation of CPR is extended from 15min to 30min in certain SPECIAL CASES • Cold water drowning • Hypothermia • Barbiturate OD • Electrocution • Lightning strike

6. Cardiac Arrest • Adult with AED • If pt is <14yr or shorter than Broselow tape (5feet)- Medical Arrest Without AED or Pediatric Medical Arrest with AED • If pt is a newborn go to protocol - Pediatric -Newborn resuscitation

7. Cardiac Arrest • 1) Confirm arrest • Call for ACLS backup ASAP • Check breathing, give 2 breaths if indicated, & check pulse 6 seconds

8. Cardiac Arrest • Assessment • Quickly obtain info (15-30sec) from witnesses to determine whether resuscitation should be initiated & by what means. • As time allows, obtain additional info including preceding events & symptoms, PMH.

9. Cardiac Arrest • If downtime of the pt is known to be <4min, then initiate resuscitation w/ the AED • If the downtime of the pt is unknown, or is known to be >4min, then initiate resuscitation w/ CPR

10. Cardiac Arrest • Apply AED • Turn on AED & follow prompts • After initial rhythm analysis, the AED will either recommend a shock or not. Allow the AED to deliver a shock as indicated

11. Cardiac Arrest • Airway • Secure airway utilizing OPA/NPA or ALS airway (Combitube or King)

12. Cardiac Arrest • CPR/AED- cycle 1 • 1 or 2 rescuer CPR (30:2). Compress 100/min • Ventilate • Do not over-inflate • Do not ventilate too quickly

13. Cardiac Arrest • CPR/AED- cycle 1 • If AED is already attached to the pt, perform CPR until the AED prompts for the next analysis (approx 2min). Do not check pulse before AED analysis • If AED states “shock advised” follow prompts on AED to shock the pt • After shock is done, the AED will state “shock delivered”. Do not check pulse • If AED states “no shock advised” then check carotid pulse for 6 seconds • If there’s a pulse>>>

14. Cardiac Arrest • If AED is not yet attached to pt, perform 2min of CPR, then attach AED to pt. After initial rhythm analysis, the AED will either recommend a shock or not • If AED states “shock advised” follow prompts on AED to shock the pt. After shock is done, the AED will state “Shock Delivered”. Do not check pulse • If AED states “no shock advised”, then check carotid pulse for 6sec. • If pt has a palpable pulse or spontaneous respirations >>

15. Cardiac Arrest • CPR/AED - cycle 2 • Perform CPR until AED prompts for the next analysis (approx 2min). Do not check pulse before AED analysis • If AED states “shock advised” follow prompts on AED to shock the pt. After shock is done, the AED will state “Shock Delivered”. Do not check pulse • If AED states “no shock advised”, then check carotid pulse for 6sec. • If pt has a palpable pulse or spontaneous respirations >>

16. Cardiac Arrest • IV • Make 3 attempts • If successful, bolus 1-Liter LR/NS (while simultaneously performing resuscitation) • If unsuccessful- do NOT attempt to give resuscitation meds w/o IV access • 1mg Epi 1:10,000 IVP • Atropine only if pt was NOT shocked in the most recent cycle • Lidocaine administer only if pt WAS shocked in the most recent cycle 100mg IVP over 2 minutes

17. Cardiac Arrest • Note • Most AEDs are programmed to analyze heart rhythm in 2min intervals • Once IV meds are introduced into the resuscitation, CPR should be performed for 3 min after each round of meds • The parkmedic may need override the automatic cycling of the AED

18. Cardiac Arrest • CPR/AED- cycle 3 • Perform CPR for 3 min after all meds are administered • Do not check pulse before AED analysis • If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse • If AED states “no shock advised”, then check carotid pulse for 6 sec • If pt has a palpable pulse or spontaneous respirations>>> • If pt has no palpable pulse or spontaneous respirations- continue resuscitation • Epinephrine 1mg 1:10,000 IVP • Atropine (administer only if pt WAS NOT shocked in most recent cycle) • Perform CPR for 3 min after all meds are administered

19. Cardiac Arrest • CPR/AED- cycle 4 • Do not check pulse before AED analysis • If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse • If AED states “no shock advised”, then check carotid pulse for 6 sec • If pt has a palpable pulse or spontaneous respirations>>> • If pt has no palpable pulse or spontaneous respirations- continue resuscitation • Epinephrine 1mg 1:10,000 IVP • Atropine (administer only if pt WAS NOT shocked in most recent cycle) • Perform CPR for 3 min after all meds are administered

20. Cardiac Arrest • CPR/AED - cycle 5 • Do not check pulse before AED analysis • If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse • If AED states “no shock advised”, then check carotid pulse for 6 sec • If pt has a palpable pulse or spontaneous respirations>>> • If pt has no palpable pulse or spontaneous respirations- continue resuscitation • Epinephrine 1mg 1:10,000 IVP • Perform CPR for 3 min after all meds are administered

21. Cardiac Arrest • CPR/AED - cycle 6 • Do not check pulse before AED analysis • If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse • If AED states “no shock advised”, then check carotid pulse for 6 sec • If pt has a palpable pulse or spontaneous respirations>>> • If pt has no palpable pulse or spontaneous respirations- continue resuscitation • Epinephrine 1mg 1:10,000 IVP • Perform CPR for 3 min after all meds are administered

22. Cardiac Arrest • CPR/AED - cycle 7 • Do not check pulse before AED analysis • If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse • If AED states “no shock advised”, then check carotid pulse for 6 sec • If pt has a palpable pulse or spontaneous respirations>>> • If pt has no palpable pulse or spontaneous respirations- continue resuscitation • Epinephrine 1mg 1:10,000 IVP • Perform CPR for 3 min after all meds are administered

23. Cardiac Arrest • Reassess • If pt has a palpable pulse or shows signs of life, check pulse q 3 min & provide appropriate ventilatory support • If not previously attempted make 3 attempt at IV placement • If pt was not given Lidocaine during resuscitation • Hold for HR<80. • IV 100mg slow IVP over 5min (50mg IVP q 30min -max 3mg/kg)

24. Cardiac Arrest • Transport if pt has a palpable pulse or transit time to healthcare facility is <10min • Special Cases - transport if pt has a palpable pulse or transit time to healthcare facility <30min • If return to spontaneous circulation, keep AED attached to pt in “off”mode. If pt rearrests, turn the AED back to “on” mode & restart CPR/AED cycle

25. Cardiac Arrest • Cardiac Arrest • Check glucose

26. Cardiac Arrest • Differential Dx • Reversible causes • Cardiogenic shock • Cardiac dysrhythmias • Hypovolemia • Tension pneumothorax • Pericardial tamponade • Respiratory arrest • Allergic reaction • Drug/medication/toxic ingestion • Hypothermia • Hyperthermia • Drowning • Electrical injury • trauma

27. Perspective • Pathophysiology • Epidemiology • PE & Diagnostic Findings • S/S • Differential considerations • Tx

28. Questions? • References • Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA 2010. • Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York 2011. • Wolfson, Allan B. ed. , Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.