Region X SOP Equipment, Drugs, Skills

1. Region X SOP Equipment, Drugs, Skills October 2011 CE Condell Medical Center EMS System Site Code #107200E-1211 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives Upon successful completion of this module, the EMS provider will be able to: • Review the changes to the Region X SOP’s • Discuss the action, indications, contraindications, dosing, and side effects of Atrovent (Ipratropium), Etomidate, Fentanyl, and Zofran (Ondansetron) • Given equipment, demonstrate appropriate use of the humeral site for IO insertion • Given equipment, demonstrate placement of the King airway • Actively participate in case scenario presentations • Complete the 10 question pre quiz

3. Atrovent (Ipratropium Bromide)Actions • Bronchodilation of bronchial smooth muscle • Blocks action of acetycholine at parasympathetic sites in bronchial smooth muscle (an anticholinergic drug) • Will dry up excessive secretions • Onset 5 - 15 minutes • Duration 4 - 6 hours

4. Atrovent (Ipratropium Bromide) Indications • Treatment of bronchospasm due to asthma, COPD, bronchitis, emphysema • Not used for immediate relief but for maintenance of effects from bronchospasm • Therefore helpful when mixed with Albuterol • Albuterol used for the rescue, Atrovent for the longer effects • If taken at home, can be repeated by EMS upon their arrival

5. Atrovent (Ipratropium Bromide)Contraindications • Hypersensitivity to atropine • No age-related precautions • Children and elderly • Unknown if passes through to breast milk • Peanut allergies are related to the metered dose prescription; not the product used in Region X

6. Atrovent (Ipratropium Bromide) Dosing • Adult and peds • 0.5mg / 2.5 mL ampule • To be mixed with Albuterol in nebulizer cup • First dose only; Albuterol alone after first dose

7. Atrovent (Ipratropium Bromide)Side Effects • Coughing • Dizziness • Insomnia, restlessness • Nausea • Dry mouth • Headache

8. Etomidate Actions • Nonbarbiturate hypnotic, sedative • Short acting drug to produce rapid anesthesia • Minimal cardiovascular effects • Onset 1 - 2 minutes • Duration generally 3 - 5 minutes

9. Etomidate Indications • Sedation to relieve apprehension or impair memory during intubation • Effects may be increased when combined with other central nervous system (CNS) depressants

10. Etomidate Contraindications • Hypersensitivity to Etomidate • Labor and delivery • Insufficient data to support its use • Contact Medical Control for clarification

11. Etomidate Dosing • Adult and peds • 0.3 mg/kg slow IVP/IO • Give over 30-60 seconds • Maximum dose 20 mg • Typical 150 pound person meets the max of 20mg • Too rapid an injection may result in hypotension • Treat with fluid challenge • 0.3 mg is an average dose • Dosing charts for adults and peds available in SOP’s

12. Etomidate Side Effects • Nausea and vomiting • Dysrhythmias • Breathing difficulties • Hypotension – treat with fluids • Hypertension • Transient involuntary muscle movement • Myoclonic activity (coughing, hiccups) • Appears as muscle twitching especially if given too rapidly • Usually resolves spontaneously, does not interfere with ability to finish securing the airway • Pain at injection site • Less when larger, more proximal sites used

13. Fentanyl Actions • Opioid analgesic • Alters pain reception • Increases pain threshold • Also known as • Duragesic • Onset 7-8 minutes • Duration ½ - 1 hour

14. Fentanyl Indications • Sedation • Pain relief • Adjunct to general or regional anesthesia • In cardioversion, Versed (midazolam) used for the initial sedation and as an amnesic • Fentanyl used for any pain/discomfort

15. Fentanyl Contraindications • Increased intracranial pressure (ICP) • Severe hepatic (liver) or renal impairment • Severe respiratory depression • Cautious use in bradycardia • Readily crosses the placenta • May prolong labor if given in first stage of labor or before cervical dilation of 4-5 cm

16. Fentanyl Dosing • Adult and peds • 0.5 mcg/kg slow IVP/IN/IO • Administer over 1-2 minutes • IN route must be a rapid delivery to create a mist • Too rapid administration increases risk of skeletal and thoracic muscle rigidity resulting in larygo and broncho spasms and apnea • May repeat 0.5 mcg/kg slow IVP/IN/IO in 5 minutes • IN route must be delivered rapidly to create a mist • Max total dose is 200 mcg adult and pediatrics

17. Fentanyl Side Effects • Mixing with benzodiazepines may increase risk of hypotension and respiratory depression • Narcan an effective reversal agent • BVM should be available when medications that can cause respiratory depressant are being administered • Nausea, vomiting, diarrhea, constipation • Less nausea noted than with use of Morphine • Dry mouth • Abdominal pain • Orthostatic hypotension

18. Zofran (Ondansetron) Actions • Antinausea, antiemetic • Half-life 3 – 6 hours

19. Zofran (Ondansetron)Indications • Prevention/treatment of nausea and/or vomiting

20. Zofran (Ondansetron) Contraindications • Hypersensitivity to the medication • Caution: • A 9/15/11 FDA Medwatch Safety Alert issued for patients with long QT syndrome • May develop tachydysrhythmia (i.e.; Torsades) • Watch for dysrhythmias • Patient may complain of a racing feeling • Palpate the pulse and compare with the initial assessment

21. Zofran (Ondansetron) Dosing • Adult 4 mg IVP/IO over 30 seconds • Peds <40 kg 0.1 mg/kg IVP/IO over 30 seconds • Peds >40 kg 4 mg IVP/IO over 30 seconds • May repeat once after 10 minutes

22. Zofran (Ondansetron) Side Effects • Anxiety • Dizziness • Drowsiness – especially noted in children • Headache • Fatigue • Constipation, diarrhea • Hypoxia • Urinary retention

23. The King Airway • Alternate airway device • Supraglottic, supralaryngeal, extraglottic, oropharyngeal • Back up for failed or difficult intubation attempts in the field • Provides a ventilatory device

24. King Airway • A dual lumen supraglottic airway • 2 cuffs inflated with a single valve • Device sits in the larynx above the vocal cords • Distal cuff seals esophagus • Proximal cuff seals oropharynx • Throat at the back of the mouth Balloons inflated

26. King Airway Contraindications • Persons less than 4 feet tall • Presence of a gag reflex • Check for presence of a blink reflex • Stroke eye lashes looking for eye movement • Tap space between eyes at bridge of nose to check for blink reflex • Known esophageal disease • Caustic ingestion

27. Sizing • Choose color-coded size based on patient height • 4-5' tall – size 3 – yellow • Think “3-4-5” • 5-6' tall – size 4 – red • Think “4-5-6” • >6' tall – size 5 – purple • Think “5-6”

28. Procedure • Pre-oxygenate patient via BVM • May need to insert an oropharyngeal airway (OPA) or nasopharyngeal airway (NPA) • Pre-oxygenate for 3 minutes • Prepare to remove airway adjunct just prior to insertion of King airway

29. Procedure cont’d • Assemble and check equipment • King airway • Syringe • Water-soluble lubricant • BVM • Stethoscope • Device/tape to secure tube

30. Procedure cont’d • Lubricate back side of tip of King airway • Avoid lubricant in ventilation ports • With non-dominate hand, hold mouth open and apply chin lift • Must use a chin lift to facilitate passing the device • In the presence of trauma, manual control of the c-spine needs to be simultaneously performed • Hold King airway at connector with dominant hand

31. Procedure cont’d • Using lateral approach, introduce tip into patient’s mouth • Blue orientation line should be touching corner of mouth • Advance tip behind base of tongue while rotating tube to midline • Blue orientation line faces chin of patient

32. Procedure cont’d • Without excessive force, advance tube until base of colored connector is aligned with patient's teeth or gums • Tube must be inserted all the way in, cuffs inflated, and then withdrawn into correct position

33. Procedure cont’d • Inflate pilot balloon with appropriate volume of air • Inflate using the minimum volume of air posted • Ranges printed on side of tube as reference • Size 3 (yellow) – 45 - 60 mL • Size 4 (red) – 60 – 80 mL • Size 5 (purple) – 70 -90 mL • Remove syringe while holding down plunger to avoid pulling air out of cuffs

34. Procedure cont’d • While bagging, gently and simultaneously withdraw King airway until breath sounds are auscultated and ventilation is easier • Adjust cuff inflation if necessary if air leak is heard

35. Procedure cont’d • Confirm device placement • 5 point auscultation • Negative epigastric sounds • Bilateral breath sounds • Equal rise and fall of chest • ETCO2 yellow or capnography 35-40 mm Hg • Apply cervical collar to assist in maintaining tube position

36. Nice to Know! • “…no inadvertent tracheal intubation, which would lead to complete obstruction of the airway occurred. • Genzwuerker H et al. The Laryngeal Tube: A New Adjunct for Airway Management. Prehosp Emerg Care 2000; 4(2): 168-72.

37. King Airway Insertion Tips • Use a chin lift and lateral approach • Facilitates placement of distal tip around posterior pharynx and under base of tongue • Keep tip and tube midline • If advanced laterally, tip may enter a blind pouch (pyriform fossa) and bounce back during inflation

38. King Airway Insertion Tips • Insertion depth MUST be adjusted to maximize ventilation • Best insertion depth is to place colored adapter at teeth or gum line, inflate cuffs and withdraw until ventilations adequate

39. Documentation King Airway • Size King airway used • Confirmation method • Rate of ventilations provided • One breath every 6 seconds • Works for patients with or without a pulse • Works for the patient receiving CPR • Can write the word “King” in space next to “ET” and finish documentation in notes section

40. EZ IO • The alternative IV access method • Rapid placement • Rapid entry into the bloodstream • Consider if patient NEEDS IV access or do YOU just want IV access? • Remember in the patient with a stroke • Minimize IV sticks – they’ll be receiving fibrinolytics that will affect clotting time

41. Highlights on EZ IO Needles • Avoid prejudicing decisions of needle size to patient population • No longer referring to “pink=peds”, “adult” and “bariatric” needles • Needles referred to by their length • 15mm (pink), 25mm (blue), and 45mm (yellow) • Half of peds needs a 15mm needle and half need 25mm • Determine needle length needed by palpating over the site • Let the drill pull itself in, don’t push the needle in • Stop drilling when loss of resistance is felt

42. EZ IO Needles • Note the black identifying line mark on each needle • Need to keep at least one black line visible once needle touches bone and prior to drilling

43. EZ IO Needle Sizing • Insert needle tip into site until resistance is felt • The needle tip is touching bone • If at least one black mark is still visible, there is enough needle length remaining to secure into the site

44. EZ IO 45 mm Yellow Needle • Used for obesity over the landmark site • Some patients may be large in select areas of their body but not in their extremities • Think of the patient with COPD • Palpation and clinical judgment used

45. EZ IO 45mm Needle • Recommended for the humeral site in all patients over 40 kg (88 pounds) • A back-up site alternative to the tibial site • Humerus a relatively softer bone • Not a weight bearing bone • Longer needle provides more stability in the bone • Aim needle in slightly inferior (downward) direction • Imagine the tip moving toward the arm socket or toward an imagined space between the heart and the spine • Immobilize the arm after IO insertion to avoid dislodging needle

46. Palpating the Humeral Head G = greater tuberosity L = lesser tuberosity M = metaphysis Target site is the greater tuberosity

47. Humeral IO Insertion Site • Adduct patient's arm over their abdomen • In supine patient, elbow pulled back, resting on the bed/backboard,/ground makes this site more prominent • Push your thumb into humerus about mid-shaft, palpate up the humerus until you feel the bone bow out • This is the surgical neck • Continue to palpate up about 1 finger width (1 cm) • This will be the center of the greater tubercle of the humerus

48. Humeral IO Insertion Site Alternate identification of site: • Hit your palm on anterior portion of the shoulder • You feel a golf ball sized bone in the natural indentation of your palm • This is the greater tubercle which is just anterior to midline • To find midline, square up the shoulder and visualize where the middle is

49. Humeral IO Insertion Site Alternate identification of site: • Gently lift arm straight up via the elbow • Keep arm and elbow next to body • Lift up like trying to touch the shoulder to patient's ear • Proximal humerus very pronounced and easy to identify

50. Humeral IO Site • As a non-weight bearing bone, humerus softer than tibia • Will need to immobilize arm to prevent movement • Secure IV site to avoid inadvertent needle removal