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Region X SOP Review

Region X SOP Review. December 2009 CE Advocate Condell Medical Center EMS System Site Code #107200E-1209. Prepared by Sharon Hopkins, RN, BSN, EMT-P. Objectives. Upon successful completion of this module, the EMS provider will be able to:

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Region X SOP Review

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  1. Region X SOP Review December 2009 CE Advocate Condell Medical Center EMS System Site Code #107200E-1209 Prepared by Sharon Hopkins, RN, BSN, EMT-P

  2. Objectives Upon successful completion of this module, the EMS provider will be able to: • 1. identify the signs and symptoms of an acute asthma attack • 2. identify the Region X SOP treatment for acute asthma. • 3. identify signs and symptoms of COPD. • 4. identify the Region X SOP treatment for COPD. • 5. identify signs and symptoms of acute pulmonary edema.

  3. Objectives cont’d • 6. identify the Region X SOP treatment for acute pulmonary edema. • 7. identify signs and symptoms of a diabetic reaction. • 8. identify the Region X SOP treatment for a diabetic reaction. • 9. identify signs and symptoms of hypertensive crisis. • 10.identify the Region X SOP treatment for hypertensive crisis. • 11.identify assessment of acute abdominal pain.

  4. Objectives cont’d • 12. identify the Region X SOP treatment for acute abdominal pain. • 13. identify assessment of acute flank pain. • 14.identify the Region X SOP treatment for acute flank pain. • 15.identify indications, contraindications, dosing, side effects, and documentation for Albuterol. • 16. identify indications, contraindications, dosing, side effects, and documentation for Lasix.

  5. Objectives cont’d • 17. identify indications, contraindications, dosing, side effects, and documentation for Nitroglycerin. • 18. identify indications, contraindications, dosing, side effects, and documentation for Morphine. • 19. identify indications, contraindications, dosing, side effects, and documentation for Dextrose. • 20. identify indications, contraindications, dosing, side effects, and documentation for Glucagon.

  6. Respiratory System • Functional unit – the alveoli • Tiny air sacs at the distal end of the respiratory system • Oxygen is removed from the air and bound with hemoglobin in the blood • Carbon dioxide is displaced from blood into the alveoli and blown out as expired air • Measureable with ETCO2 detectors

  7. Acute Asthma • Chronic inflammatory condition • Reversible widespread narrowing of the airways (bronchospasm) • Symptoms usually develop in response to a trigger • Viral infection, dust, cold, smoke • Produces: • intermittent wheezing • excess mucous production • edema of the airways

  8. Acute Asthma • YOU CAN DIE FROM ASTHMA • Overall mortality rate 5% • 1 in 100 hospitalized patients die per year • Death rates are higher in persons less than 35 years of age • Fastest growing asthma rates are in children under 5

  9. Triad of Asthma Airway edema Increased mucous production Bronchospasm

  10. Signs and Symptoms of Asthma • Bronchospasm • Constriction of smooth muscle that surrounds the larger bronchi in the lungs • Air moving thru constricted tubes vibrates the passageway creating wheezing • Wheezing is widespread • Bronchoconstriction may be so severe that no breath sounds are heard • Ominous sign

  11. Signs and Symptoms of Asthma • Increased mucous production • Thick secretions plug the distal airways • More air trapping occurs • Dehydration makes secretions even thicker which worsens air trapping • Taking antihistamines contributes to increased dryness • Secretions thicken

  12. Signs and Symptoms of Asthma • Bronchial edema • Wall of the bronchial tubes swell which narrows the lumen (opening of the tube) • Swelling of bronchioles creates turbulent airflow, wheezing, and air trapping

  13. Treatment Goals for Asthma • Reverse bronchospasms with a bronchodilator medication • Thin mucous secretions with improving hydration (ie: IV fluids) and expectorants • Reduce airway edema with corticosteroid medications • Administered/prescribed in the hospital

  14. COPD • Chronic obstructive pulmonary disease • 2 distinct entities • Emphysema • Chronic bronchitis • These populations have little to no respiratory reserve

  15. Hypoxic Drive • A rare occurrence in a small population of the most chronic form of pulmonary disease and in the end stages • Brain switches to a hypoxic drive to breathe • Decreased levels of O2 stimulate breathing • Increased levels of CO2 no longer a stimulus • For the patient that becomes apneic, bag them • Adult rate 10 - 12 breaths per minute • Allow for adequate exhalation time

  16. Signs and Symptoms Emphysema • Barrel chest – chronic over inflation of chest • Tachypnea – attempt to maintain normal CO2 levels • Wasting muscle mass - use extreme amounts of energy to breathe • Pursed lip breathing – attempt to exhale as much CO2 as possible • “Pink puffer” – usually always good color

  17. Signs and Symptoms Chronic Bronchitis • Excessive mucous production in bronchial tree • Chronic or recurrent productive cough • Usually somewhat obese • Congested • Bluish complexion • Chronically elevated levels of CO2 • Chronically lower levels of O2

  18. Region X SOPAsthma/COPD with Wheezing • Routine Medical Care • Obtain pulse oximetry before O2 application, if possible, as a baseline • Obtain VS, breath sounds, pulse oximetry • Albuterol 2.5 mg/3ml • O2 flow at 6L/minute • Transport • Contact Medical Control to consider CPAP with COPD

  19. Albuterol • Sympathomimetic, bronchodilator • Relaxes smooth muscles in bronchial tree to relieve constriction • The drug has more selectivity in the lungs than influence in the heart • Use to treat patient presenting with wheezing • Could produce tachycardia • Administer 2.5 mg in 3 ml of solution for all ages

  20. Albuterol cont’d • Watch for tachycardia, tremors, restlessness, dysrhythmias • For best results, patient needs to be coached while inhaling • Encourage slower breaths • Encourage deeper breaths • Encourage inhaled breaths to be held longer • Medication needs to get to the lungs to be effective

  21. Acute Pulmonary Edema • Lungs swell up with fluid that migrated from the blood plasma into the walls of the capillaries and alveoli of the lungs • Gas exchange is compromised before signs and symptoms are evident • One of the most common causes of pulmonary edema is acute MI

  22. Signs and Symptoms Acute Pulmonary Edema • Crackles in lung bases at end of inspiration – early sign • Alveoli popping open as lungs reach maximum inflation • As condition worsens, crackles heard higher up in the lung fields • Productive cough of watery sputum often pink tinged (red blood cells) • Bubbling and foaming froth • From air forced out of fluid filled lungs

  23. Signs and Symptoms cont’d • Dyspnea at rest • Extreme restlessness • Tachypnea • Tachycardia • Diaphoresis • Cyanosis • Decreased SpO2 • Stable if B/P >100; unstable if B/P <100

  24. Region X SOP – Stable Acute Pulmonary Edema • Patient alert; skin warm & dry; B/P >100 • Nitroglycerin 0.4 mg sl • Repeated every 3-5 minutes • Maximum 3 doses • Consider CPAP • Lasix 40 mg IVP • 80 mg if patient takes oral Lasix at home • Morphine 2 mg slow IVP (over 2 min) • May repeat every 2 min as needed to a maximum of 10 mg total • If wheezing, contact Medical Control to consider Albuterol nebulizer • Transport

  25. Lasix • Loop diuretic that inhibits reabsorption of sodium and chloride and acts as a diuretic • Diuretic effect takes about 20 minutes • Produces venodilation and pools blood away from the heart to decrease preload • Venodilation effect almost immediate

  26. Lasix cont’d • Used in CHF and pulmonary edema • First as venodilator • Second as diuretic • Small potential of allergic reaction in patients with allergy to antibiotic sulfa drugs • Cautious use in hypotensive conditions • Administer 40 mg slow IVP • Give 80 mg if patient takes at home • May cause hearing loss or ringing in ears if given rapidly over repeated doses

  27. Nitroglycerin • Strong venodilator • Relaxes smooth muscles causing dilation of venous and arterial blood vessels • Reduces blood volume return to the heart (preload) reducing the work-load of the heart • Onset within minutes • Useful in pulmonary edema due to vasodilation effect

  28. Nitroglycerin cont’d • Avoid using if patient has taken a viagra type drug within past 24-36 hours • Combination may produce irreversible hypotension leading to shock or death • Administer 0.4 mg sl • May repeat up to 3 doses total • Carefully monitor B/P response before and after each dose

  29. Nitroglycerin cont’d • Side effects • Headache – venodilation • Hypotension – venodilation • Dizziness – venodilation • Postural syncope – venodilation • Nausea and vomiting – catecholamine effect • Metallic taste – effect of medication

  30. Morphine Sulfate • Narcotic analgesic, opioid • Depresses CNS activity • Creates sense of euphoria • Venodilator • Increases venous capacity pooling blood away from returning to the heart (decreased preload) • Used in pulmonary edema to reduce preload

  31. Morphine cont’d • If systolic B/P >100 can give Morphine 2 mg IVP slowly over 2 minutes • May repeat every 2 minutes as needed • Maximum dose 10 mg • Evaluate blood pressure and respiratory status prior to each dose

  32. Region X SOP – Unstable Acute Pulmonary Edema • Altered mental status; B/P < 100 • Contact Medical Control • CPAP on orders of Medical Control • Consider Cardiogenic Shock Protocol • Dopamine drip to improve blood pressure • Treat dysrhythmias per protocol • If wheezing, contact Medical Control to consider Albuterol nebulizer

  33. Diabetes Mellitus • Impairment of the body’s ability to metabolize simple carbohydrates (glucose) • Pancreas does not produce enough insulin or cells do not respond to insulin produced • Develop elevated levels of glucose in the blood and urine • Typical presentation • Urinating large quantities of urine containing large amounts of glucose • Extreme thirst • Deterioration of body functions

  34. Diabetes Mellitus • There is no cure • Treatment focuses on maintaining glucose levels in the normal range • Dietary habits and activity must be monitored • Will have the biggest impact on improving quality of life and avoiding complications

  35. Type I Diabetes Mellitus • Most patients do not produce any insulin • Generally strikes children more than adults • Requires daily injections through out their lives • Requires strict diet control • Requires a balance of activity

  36. Type 2 Diabetes Mellitus • Most common form of diabetes • Glucose levels are elevated • Typically develops later in life • Becoming more common in younger people • Body cannot effectively use the insulin produced • Onset of signs and symptoms is usually slow/gradual and often go unrecognized by the patient

  37. Type 2 Diabetes Mellitus • Signs and symptoms • Fatigue • Nausea • Frequent urination • Thirst • Unexplained weight loss • Blurred vision • Frequent infections that heal slowly • Being cranky, confused, or shaky • Unresponsiveness • Seizures

  38. Hyperglycemia • Elevated levels of sugar • Excessive food intake • Insufficient insulin dosage • Infection or illness present • Stresses (ie: surgery, stress events) • Gradual onset (hours to days) • If untreated, will lead to diabetic ketoacidosis • Life threatening condition of high levels of certain acids in the body

  39. Hypoglycemia • Too much insulin taken • Not enough food eaten • Brain is starved when it’s energy source (glucose) is lacking • Cerebral dysfunction becomes evident • Headache, confusion, slurred speech, irritability, seizures, coma

  40. Field Treatment Goals • Hyperglycemia • Patient is dehydrated and needs fluid resuscitation • Hypoglycemia • The brain is starving for glucose and the patient needs sugar as quickly as possible

  41. Signs and Symptoms Hyperglycemia • Hours to days to develop • Warm and dry skin (dehydrated) • Normal to low B/P (dehydrated) • Normal to rapid pulse (dehydrated) • Very thirsty (dehydrated) • Deep, rapid breathing (Kussmauls) (attempting to blow off excess acid CO2) • Sweet, fruity smell to breath (acetone) • Restless, just doesn’t feel well

  42. Signs and Symptoms Hypoglycemia – Insulin Shock • Quick onset within minutes • Pale and moist skin • Low B/P • Rapid, weak pulse • Normal or rapid breathing • Irritable, confused, seizures, or coma • Rapid response to treatment

  43. Region x SOP - Hyperglycemia • Routine Medical Care • History of last med dose and if patient has eaten and when • Obtain capillary blood glucose level • Use lancet and fingertip or forearm site • IV fluid challenge 200 ml • Reevaluate condition • May repeat fluid challenge 200 ml 2 more times • Transport

  44. Region X SOP - Hypoglycemia • Routine Medical Care • History of last med dose and if patient has eaten and when • Obtain capillary blood glucose level • Use lancet and fingertip or forearm site • If blood sugar <60, administer Dextrose • Adult 16 and over – 50 ml 50% IVP/IO • 1 – 15 years – D25% IVP/IO 2ml/kg • <1 year old – D12.5% IVP/IO 4ml/kg

  45. Dextrose • A carbohydrate used to supply glucose (sugar) • Rapid onset • Useful in known hypoglycemic case and unresponsiveness for unknown cause • Better to over treat the hyperglycemic patient than to under treat the hypoglycemic patient

  46. Dextrose cont’d • Dose related to age • Adult 16 and over – 50 ml 50% • 1 – 15 years old – D 25% 2 ml/kg • Under 1 – D 12.5% 4 ml/kg • Dilute D 25% 1:1 to make D 12.5% • Administer Dextrose slowly • Drug is hypertonic and acidic and can be irritating to veins • Can be damaging to tissue if IV/med infiltrates

  47. Glucagon • A hormone to stimulate breakdown of glycogen (stored form of glucose) in the liver • Helpful when an IV cannot be established and Dextrose is desired • Administer 1 mg / 1 unit • May take up to 20 minutes to work IF there are glucose stores available

  48. IV Established After Glucagon • IV established after Glucagon given • Recheck glucose level • If glucose level remains < 60, administer Dextrose • Drug must be reconstituted prior to administration • Roll reconstituted drug in hands • Check that all flecks have dissolved

  49. Hypoglycemia Treatment • If no response to Dextrose in the adult patient, repeat 50 ml D50% IVP • If unable to establish an IV, administer Glucagon 1 unit (1 ml) IM • Glucagon may take up to 20 minutes to work if glucose stores are available in the liver

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