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Electrical Therapies Case Scenarios

Electrical Therapies Case Scenarios. June/July 2014 CE Condell Medical Center EMS System IDPH Site Code: 107200E-1214 Sharon Hopkins RN, BSN, EMT-P Rev 6.15.14. Objectives. Upon successful completion of this module, the EMS provider will be able to:

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Electrical Therapies Case Scenarios

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  1. Electrical Therapies Case Scenarios June/July 2014 CE Condell Medical Center EMS System IDPH Site Code: 107200E-1214 Sharon Hopkins RN, BSN, EMT-P Rev 6.15.14

  2. Objectives • Upon successful completion of this module, the EMS provider will be able to: 1. Actively participate in case scenario discussion. 2. Actively participate in review of a variety of EKG rhythms and 12 lead EKG’s. 3. Actively participate in review of selected Region X SOP’s. 4. Describe the intervention or treatment plan for the case presented following Region X SOP guidelines.

  3. Objectives cont’d 5. Actively participate in using your department monitor/defibrillators to review the process of pacing, synchronized cardioversion and defibrillation skills. 6. Review safety procedures observed when using electrical therapies. 7. Review CPR guidelines per the American Heart Association (AHA) 2010 Guidelines. 8. Review responsibilities of the preceptor role. 9. Successfully complete the post quiz with a score of 80% or better.

  4. Electrical Therapies for Patient Care • Usually used when the patient is unstable and immediate therapies are required • Measuring patient stability = assessing perfusion • Evaluate level of consciousness • Brain function VERY sensitive to level of oxygen perfused as well as glucose • Reacts quickly when O2 and glucose supplies drop • Evaluate blood pressure • Falls when all levels of compensation are exhausted

  5. Transcutaneous Pacing (TCP) • Electrical pacing of heart through the skin • Beneficial in symptomatic bradycardia • Sinus bradycardia • High-degree heart block • Second degree Type II (Classical) • Third degree – complete • Atrial fibrillation with slow ventricular response • Any other bradycardic rhythm causes symptoms

  6. TCP • Symptomatic bradycardia • Patient’s symptoms related to poor perfusion to vital organs • Patient evaluated on THEIR response to their level of perfusion; not just on the heart rate number • Example • Conditioned athletes normally maintain excellent perfusion with a heart rate in the 40’s

  7. TCP • Monitoring electrodes placed in usual fashion • TCP pad placement • Anterior chest pad (-) placed in apical area • Posterior pad (+) placed in mid-upper back area • Between spine and scapula • Bone is poor conductor of electricity so avoid placement over a bone

  8. TCP Settings • Rate: 80 / minute • Sensitivity: Auto / demand • Output: mA started at 0 and turned up until capture noted with lowest energy level • Capture evident with wide QRS complex following a pacer spike • Evaluate perfusion • LOC • B/P

  9. Pain Management For TCP • TCP use is painful/uncomfortable for the patient • Administer Valium as a benzodiazepine to relax the patient • 2 mg IVP/IO over 2 minutes • May repeat every 2 minutes as needed to a max of 10 mg • To manage pain, administer Fentanyl, an opioid • 1 mcg/kg IVP/IO/IN • May repeat same dose in 5 minutes as needed to max 200 mcg total dose • Watch for respiratory depression in both categories of meds

  10. Synchronized Cardioversion • A controlled form of defibrillation with delivery of lower energy settings • Used when the patient still has an organized rhythm and a pulse • Electrical discharge delivered during R wave of QRS • Current delivered on downslope of T wave (relative refractory period) could cause the rhythm to deteriorate into ventricular fibrillation (VF)

  11. Stable vs. Unstable Tachycardia • In tachycardia, the ventricles contract so fast they are unable to properly fill to capacity • Contract out smaller stroke volumes than normal • Leads to overall decrease in cardiac output • For stability: • Check level of consciousness - first indicator to change • Check B/P - last indicator to change

  12. Synchronized Cardioversion Indications • Unstable SVT • Unstable rapid atrial flutter /fibrillation (narrow complex tachycardia) • Unstable ventricular tachycardia (VT) or wide complex tachycardia • Peds probable SVT with poor perfusion after no response to meds • Peds possible VT with poor perfusion • Peds probable SVT or VT with adequate perfusion and after no response to meds

  13. Synchronized Cardioversion Sedation • The conscious patient should be sedated if at all possible! • This is a painful procedure • But, do not delay procedure to sedate • Sedation with benzodiazepine • Versed 2 mg IVP/IO every 2 minutes titrated • Max 10 mg total dose • Pain control with Fentanyl 1 mcg/kg • Repeated in 5 minutes; max total dose 200 mcg

  14. Set Up For Synchronized Cardioversion • Activate synchronizer mode button • Watch for flagging of the R wave • Look and call “all clear” • Hold oxygen source away from the patient • Press and hold discharge buttons until machine discharges on next R wave • Will be momentary delay • Assess the monitor and patient

  15. Flagging the R Wave

  16. Precautions with Cardioversion • Patients in atrial fibrillation >480 not on anticoagulants have increased risk of blood clot formation in quivering atria • Cardioversion causes the atria to contract and could break off a clot increasing risk for stroke • Avoid cardioversion if at all possible on atrial fibrillation patient until detailed and further evaluation can be completed (if possible)

  17. Defibrillation • Non-synchronized delivery of energy during any part of the cardiac cycle • Cells depolarized allowing them to repolarize uniformly • Electrical therapy causes the heart to contract simultaneously • The goal is to allow the SA node (dominant pacemaker) to take over the electrical control of the heart

  18. Defibrillation Back Ground • Most defibrillator units are biphasic • This waveform allows use of less energy • Less energy = less myocardial/tissue damage • Current moves in one direction and then travels back in the opposite direction • Need to know YOUR respective manufacturer’s recommendation for energy settings • Suggestion: place a label next to screen with YOUR setting recommendations

  19. Increasing Success Rate for Defibrillation • Time from onset of VF – sooner the better • Perform CPR ONLY until the defibrillator is set up and ready to go • Pad placement • 1 to right of upper sternum below clavicle • 1 to left of left nipple anterior axillary line over apex of heart • Do not place over pacemaker or internal defibrillator • Confirm pads are secured tightly to chest wall with no air gaps

  20. Set Up For Defibrillation • Perform CPR while setting up machine and placing pads • Hold CPR to analyze rhythm • Confirm VF or pulseless VT • Charge unit as recommended by manufacturer • May perform CPR just until unit is charged • Look and call “all clear” • Hold oxygen source away from patient • Depress defib buttons • Resume CPR for 2 minutes

  21. Shockable Rhythms Pulseless VT Polymorphic VT Course VF Results post defibrillation Now check for a pulse

  22. Summary Electrical Therapies • Know YOUR particular brand monitor/defibrillator • Know how to operate YOUR equipment • Check equipment every shift for adequate stocking of supplies • Know how to trouble shoot YOUR equipment • Acknowledge when YOUR equipment requires regular monitoring electrodes to be placed IN ADDITION to defib/pacing/cardioversion pads

  23. Obtaining and Transmitting 12 Lead EKG’s • Review placement of electrodes for obtaining 12 lead EKG’s • Review YOUR equipment process for transmitting to the hospital • Remember to state in report YOUR interpretation for presence/absence of ST elevation • THEN read word for word the print-out interpretation

  24. Electrode Placement for 12 Lead EKG’s For every person, each precordial lead placed in the same relative position • V1 - 4th intercostal space, R of sternum • V2 - 4th intercostal space, L of sternum • V4 - 5th intercostal space, midclavicular • V3 - between V2 and V4, on 5th rib • V5 - 5th intercostal space, anterior axillary line • V6 - 5th intercostal space, mid-axillary line

  25. Precordial LeadPlacement

  26. Case Scenario Discussions • Read the cases presented • Discuss what your general impression is • Determine appropriate interventions based on the most current Region X SOP’s dated “IDPH Approved April 10, 2014” • Pocket sized protocols being printed by the Region • Full size copies forwarded to the Medical Officer for department distribution

  27. Case Scenario #1 • 49 y/o male got arm caught in machine at work • Large open wound noted to left forearm • Large amount of blood loss evident • Make-shift tourniquet applied by co-workers

  28. Case Scenario #1 • What are the steps in controlling bleeding? • Direct pressure with gloved hand • Direct pressure with gauze • Elevation not found to have any advantage or disadvantage • Pressure points usually not effective • Operator error – not enough pressure applied • EMS tourniquet placed if bleeding not controlled

  29. Case Scenario #1 • What are the steps for CAT application? • Place as far distally as possible at least 2 inches proximal to wound on bare skin • Tighten windlass until bleeding stops; pulse no longer palpable • Monitor for further bleeding • Consider pain management • Lower leg injuries may require tourniquet placement on thigh vs calf

  30. Case Scenario #1 • Would you remove tourniquet applied by by-standers? • Case by case decision • Most tourniquets in this situation have been inappropriately applied and with improper technique • EMS would remove the tourniquet to evaluate the site and then treat based on EMS assessment

  31. Case Scenario #1- Identify the Rhythm • Regular R to R intervals; rate 130 • P waves rounded, upright • PR interval 0.12 – 0.20 seconds Sinus tachycardia

  32. Case Scenario #1 • What would you do for pain control with stable vital signs? • Administer Fentanyl 1 mcg/kg IVP/IN/IO • May repeat same dose in 5 minutes • Maximum total dose 200 mcg • What side effects should you watch for with Fentanyl? • Fentanyl is an opioid so watch for respiratory depression • Reversible with Narcan – narcotic antagonist • Cardiovascular effects (i.e.: drop in blood pressure) not a problem with Fentanyl like it may be with Morphine

  33. Case Scenario #1 • When would the QuikClot dressing be used? • Failure to control bleeding after application of tourniquet • Bleeding not controlled with direct pressure to non-extremity areas • Should the initial dressings remain in place? • No; QuikClot needs to be placed directly over the wound to be effective • Is direct pressure still required with Quikclot? • Yes for 2-3 minutes or until bleeding stops • Do not peek at the wound which disturbs the clot

  34. Case Scenario #1 Follow-up • To OR on day of admission • Large soft tissue injury with numerous small metallic foreign bodies • Non-displaced fracture ulnar styloid • OR for exploration and repair of wound • Initially unable to extend wrist but able to move 3rd, 4th, 5th digits slightly • 3 days later reports electrical shooting pain to left mid forearm • 4 days later discharged home; some movement of fingers

  35. Case Scenario #2 • 72 year-old patient presents with palpitations and indigestion for several hours • VS: B/P138/88; P – 84; R – 18; SpO2 98% • Vague on their history but takes meds but doesn’t know what for • General impression? • Worse case scenario – cardiac • Other considerations – “ill”

  36. What’s Your Interpretation? Ventricular paced rhythm

  37. Case Scenario #2 • False ST elevation • Paced rhythms • Left bundle branch block (LBBB) • There is an appearance of ST elevation but NOT in the presence of an acute myocardial infarction process • Patient evaluated and treated in field based on signs and symptoms • Bit more challenging for everyone to assess for presence of acute process

  38. Is ST Elevation Present In This EKG? ST elevation II, III, aVF Hold NTG and morphine until consulted with Medical Control

  39. What About This EKG? Left bundle branch block

  40. EKG Interpretation • Looks like ST elevation in chest leads V 1 – V4 • Actually, this is left bundle branch block (LBBB) that also can give appearance of ST elevation that does not indicate an acute process • Remember the hints for determining a LBBB pattern • Widened QRS • Possibly notched QRS (rabbit ears) • Think of a car’s turn signal • If wide QRS predominately negative in V1, consider left bundle branch block • If wide QRS predominately positive in V1 consider right bundle branch block

  41. Case Scenario #3 • 32 year-old patient presents with 2 hours of dyspnea with increasing wheezing and increasing difficulty breathing • Patient in tripod position • Pale, slightly damp, VERY anxious • B/P 138/84; P – 98; R 32; SpO2 95% • Bilateral inspiratory and expiratory wheezing • What is your general impression?

  42. Case Scenario #3 • Impression – Acute asthma • Confirmed with history • Would you administer oxygen? • Yes – presence of respiratory difficulty even though pulse ox is over 94% • What interventions need to be provided to help this patient? • Supplemental oxygen • Bronchodilators

  43. Case Scenario #3Treatment Based on Region X SOP’s • Adult Routine Medical Care • Albuterol 2.5 mg/3ml mixed with Atrovent 0.5 mg/2.5 ml neb treatment • Needs O2 flow rate of 6 lpm to generate a mist • If no improvement, repeat above medications • If no improvement, administer Albuterol alone as a neb treatment • For severe distress, contact Medical Control to consider Epinephrine 1:1000 at 0.3 mg IM

  44. Case Scenario #3 • When is a repeat of the Duoneb of Albuterol and Atrovent automatic in the Region X SOP’s? • Adult and child asthma • Adult and child allergic reactions with wheezing • Croup

  45. Case Scenario #3 • What are the benefits of Albuterol and Atrovent? • Albuterol is a bronchodilator • Acts mostly on receptors in the lungs (Beta 2) • Minimal effects on receptors in the heart (Beta 1) but may cause an increase in heart rate • Atrovent is an anticholinergic that acts as a bronchodilator • Combination therapy increases the dilating effects in the bronchioles

  46. Case Scenario #3 • Describe wheezing and how you assess for it • Wheezes are continuous high-pitched musical sounds similar to a whistle • Air is moving through partially obstructed airways • First appear at end of exhalation • Important to not move your stethoscope to the next site too prematurely • Wheezes heard during inspiration and exhalation indicate a worsening condition

  47. Case Scenario #4 • EMS is called for a 32 y/o patient with altered level of consciousness • VS: B/P 100/56; P – 72; R – 12; SpO2 98%; GCS 11 (3, 3, 5) • History: Diabetes (blood sugar 32) • What is your impression? • Diabetic reaction – hypoglycemia – insulin shock • What is your treatment goal? • Raise the blood sugar level

  48. Case Scenario #4 • How do you raise the blood sugar level in the field??? • If IV access, administer Dextrose • Strength based on age (D50%; D25%, D12.5%) • The younger/more immature the IV site, the weaker the concentration • If no IV access, Glucagon 1 mg IM/IN • Oral glucose gel (Glutose) 15 grams

  49. Case Scenario #4 • Oral Glutose gel – 15 grams • Useful in the patient who is able to tolerate oral preparations, has an intact gag reflex and is able to protect their own airway • Available for the patient in the above condition with no access to food or fluids that would otherwise be used to raise the blood sugar level

  50. Case Scenario #4 • Can this patient sign a release / refusal for transportation? • Yes, if certain conditions are met • Patient must be awake, alert, oriented • Patient must be able to understand risks and benefits • Patient’s blood sugar must be documented as being over 60 • Document your discussion with the patient • Document your advice for transport • Document follow-up – personal physician; to call 911 if any further problems • Document D/C of IV if applicable

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