Cardiac SMO’s Will/Grundy EMS Continuing Education February 2011 Written by: Will/Grundy staff

1. Cardiac SMO’sWill/Grundy EMS Continuing Education February 2011Written by: Will/Grundy staff

2. Why Discuss Cardiac SMO’s? Well, because we are not always following them. • In July and August 2010, only 40% of eligible chest pain patients in Will/Grundy received nitroglycerin. • Eligible means appropriate BP, cardiac signs/symptoms, etc…. • In June 2010, only 25% of patients who got nitro had their BP or pain level properly reassessed after administration. • Throughout 2010, Will/Grundy medics rarely utilized pacing for symptomatic bradycardia patients. • During several vfib/vtach calls in the fall of 2010, patients never received lidocaine.

3. Awesome EMS! • Majority of paramedics/EMT’s in our system are absolutely awesome at what they do. Thank you! • With bad economy, personnel shortages, patients who think 911=taxi, frustrating nursing homes… you rise to the challenge. • We can proudly say we have the best EMS crews in Illinois right here in Will/Grundy! • So if you are having problems with appropriate use of SMO’s, we want you to know we are here to support your efforts to improve patient care.

4. If we don’t use them, we lose them. • Nationwide, there have been strong voices calling to remove skills from the EMS scope of practice. • If we don’t use ALS tools in our toolbox (in a safe and appropriate way), they may be removed. • Means we will save fewer patients. • Will also lower expectations for our performance. • And lower expectations are always a bad thing.

5. Cardiac SMO Review • So lets go over the ALS cardiac SMO’s. They are listed on the following slides. • As you go through them, discuss the notes on the slides, as well as any other medications or treatments you have questions about. • ILS/BLS providers – your trimester test will not include ALS SMO’s, but it will include questions on basic cardiac assessment which we will be practicing after this presentation.

6. Suspected Cardiac SMO • About Aspirin: • We don’t primarily give aspirin to cardiac patients for pain relief. • We give it because aspirin’s blood-thinning properties are linked to better outcomes for cardiac patients. • While aspirin can provide a small amount of pain relief, nitroglycerin and morphine are the true pain-fighters during a heart attack.

7. Suspected Cardiac SMO • Some more points to ponder: • The goal is zero pain. As long as it’s not contraindicated, nitroglycerin is one of the best ways to achieve that goal. • Blood pressure and 1-10 pain levels must be assessed before AND after each administration of nitroglycerin. • IV access is a good idea when giving nitro, in case BP suddenly bottoms out. • And an FYI: • Especially in women and diabetics, weakness, n/v/d, or arm/jaw/back/shoulder pain may be the only symptom of a cardiac event. When in doubt, do a 12-lead.

8. Cardiogenic Shock SMO • Regarding Dopamine: • We don’t use it a lot, which can make us afraid to use it when it’s called for. • But for longer transports, or when waiting for a far-off mutual aid ambulance to arrive, Dopamine can save a life. • You can’t shove fluid into a non-trauma patient forever without causing it to build up in lungs and elsewhere. • Dopamine increases cardiac output and blood pressure due to its positive inotropic (related to heart muscle) and chronotropic (related to heart rate) effects.

9. V-fib and pulseless V-tach • We are doing well as a system with immediately starting CPR, shocking and giving epinephrine. We’ve had lots of saves… great job! • But for some reason statistics show lidocaine is not always administered per SMO requirements. • If the rhythm changes out of v-fib/v-tach too quickly to draw up lidocaine, that’s fine. • But if patient remains in v-fib/v-tach, then it’s time for an antiarrhythmic… and lido is what we have. • Lidocaine math can be confusing. Practice a few scenarios where you figure a dose, a drip, etc.

10. Tachycardias • If a patient with tachycardia is unstable (chest pain, SOB, low BP, altered mental status, shock) it’s time to cardiovert. • Don’t delay cardioversion on an unstable patient while fishing for an IV. • If you do have an IV, consider using versed or your patient may not enjoy the process much. • Be sure to press “sync” before each attempt. • Some medics feel more comfortable with medications than cardioversion, but cardioverting your unstable tachycardic patient is going to help him/her more than medications.

11. PEA/Asystole • As a system, we do very well with PEA and asystole. Great job! • But it’s also worth taking a moment to remember the possible causes of PEA. • Definitely give CPR, epi and atropine. But also try a fluid bolus or a warm blanket. In the case of PEA, sometimes simple is better.

12. Bradycardia • Give atropine. But if atropine is not helping, and your patient is symptomatic, pace! • Consider versed, as pacing can be painful. • Set the heart rate at 70. Start the MA (milliamps) at zero and increase them until you feel a pulse and see a paced rhythm. • Pacing can be alarming if you haven’t done it before. The patient’s chest may twitch and bounce. Don’t worry… that’s supposed to happen. • If pacing doesn’t work or isn’t available, you will have to consider dopamine to bring the heart rate up.

13. Pulmonary Edema/CHF • CPAP and nitroglycerine are two tools that are not used as often as they should be. • CPAP offers quick relief once the patient becomes comfortable with the mask (which admittedly can take a minute or two). • Although it sounds counter-intuitive, nitro can be more effective with SOB from pulmonary edema than a nebulizer. That’s why it comes before albuterol in the SMO (if BP is high enough). • Also, be sure what you are hearing is a wheeze, not rales/crackles, before you assume it’s COPD and skip the nitro. In some cases, patients can even have both!

14. Cardiac SMO’s Conclusion • Paramedics and EMT’s in the Will/Grundy EMS System are some of the best in the state at providing the highest level of care. Our reputation across the Midwest is good and growing! • Treating patients according to the SMO’s and thoroughly documenting that treatment will allow us to continue to provide that care. • If we don’t appropriately use the ALS treatments we are given, we will lose them. • You won’t get in trouble for deviating from an SMO if you consult with medical control first, then document your reasons why an intervention was not performed. We are healthcare professionals, not EMS robots. • But if the treatment is listed on the SMO, is appropriate for the situation and is something you are trained to do, there is no excuse not to do it.

15. Cardiac Scenario Review • Your EMS coordinator has copies of several cardiac scenarios. • He or she will split you into groups or partners, and give you time to verbally run through those scenarios. • Pick someone to run the scenario while the rest play the part of medics and EMT’s on scene. Switch after each scenario. • Concentrate particularly on basic assessment skills, treatments based on your SMO’s, and your re-assessments after those treatments. • Discuss with your group members any interventions you may feel comfortable or uncomfortable with, and why. • Also discuss whether you agree with the suggested treatments. Sometimes there is not one right answer.

16. Thank You!