EMS Equipment Review

EMS Equipment Review March 2015 CE Condell Medical Center EMS System CE IDPH Site Code #107200E-1215 Prepared by: Sharon Hopkins, RN, BSN, EMT-P

Objectives Upon successful completion of this module, the EMS provider will be able to: • List indications for use of a variety of EMS equipment used in the field. • Manage a group of peers in setting up and applying a variety of equipment used in the field. • Evaluate the effectiveness of application of a variety of EMS equipment in a practical setting.

Objectives cont’d • Actively participate in review of selected Region X SOP’s as related to the topics presented. • Actively participate in review of the process of transmission of 12 lead EKG’s using department specific equipment. • Actively participate in reviewing the operation of your department monitor/defibrillator, pacing capacity, synchronized cardioversion and defibrillation at the paramedic level.

Objectives cont’d • Actively participate in HARE/Saeger traction application. • Successfully complete the post quiz with a score of 80% or better.

Equipment and Patient Interventions • There comes responsibility when using equipment in the delivery of patient care. You need to: • recognize what the problem is to know what to do • be able to distinguish what the appropriate intervention(s) is/are • understand how to properly apply and use the equipment chosen • recognize when the intervention is working as well as not accomplishing the goal • know what documentation must be done with each piece of equipment used in patient care • be knowledgeable regarding the cleaning and returning to service for each piece of equipment

Capnography Background • A continuous, non-invasive monitoring tool • Measures level of CO2 at end of exhalation • Quantitative results provides a number • Assesses respiratory status thru-out respiratory cycle • Provides current, at the moment, breath-to-breath information on patient status • Results measured as mmHg of CO2 • Normal 35 – 45 mmHg

Capnography Information • Numeric value provides end tidal (end of breath) CO2 level • Waveform is a picture representation of the CO2 value exhaled with each breath • Airway status reflected in: • ETCO2 value (mmHg) • Waveform picture • Respiratory rate

Definitions • Ventilation • Process of breathing; eliminating CO2 from body • Respiration • Exchange of gasses at alveoli level • Oxygenation • Getting O2 to tissues; measured by pulse oximetry • Diffusion • Process by which gas moves between alveoli and pulmonary capillaries (gases move from area of high concentration to areas of low concentrations)

Capnography Usefulness • Provides information on how effectively the body is: • Producing CO2 (metabolism) • Transporting CO2 (perfusion) • Exhaling CO2 (ventilations) • Goal – attain/maintain CO2 levels 35 – 45 mmHg

Capnography Usefulness cont’d • Confirms and monitors advanced airway placement • Indicates effectiveness of chest compressions • Blood must circulate through lungs to off-load CO2 for it to be exhaled • Levels expected to minimally be >10mmHg during CPR • Indicates return of spontaneous circulation (ROSC) • Sudden, sustained rise in levels toward 35-45 mmHg • Allows early interventions to be started

Capnography Usefulness cont’d • Monitor asthma & COPD conditions and response to bronchodilator therapy • Detect increased respiratory depression and hypoventilation • Tiring accessory muscles • Neuromuscular disease effect on respiratory center • Change in level of consciousness – alcohol/drug overdose, head trauma, sedation/analgesia • Seizure activity &/or post ictal period

Capnography Waveform • A-B – respiratory baseline • B-C expiratory upslope • C-D expiratory plateau • D – end of exhalation • point of measurement • D-E – inspiratory downslope

Capnography Waveforms • Hypoventilation • CO2 retained so values  • Hyperventilation • CO2 eliminated so values 

Capnography Waveforms • Asthma attack or COPD • Difficulty exhaling evidenced by slow, gradual upslope

Capnography Waveforms • Apnea or loss of advanced airway - flat line

ETCO2 Detector • End tidal (end of breath) CO2 detector • Qualitative device • Indicates presence/absence of detectable CO2 exhaled via pH sensitive paper • Does not provide specific measurement of numeric value • Color scale estimates CO2 level • Able to change as detected levels change • May take up to 6 breaths to wash enough CO2 out for proper measurement

ETCO2 cont’d • Gastric content or acidic drug contact on pH paper can affect accuracy of values detected • When perfusion decreased (shock, arrest) ETCO2 reflects change in pulmonary blood flow and CO2 level • Does not reflect ventilation status

Altered CO2 Levels •  CO2 level • Shock, cardiac arrest, pulmonary embolism, bronchospasm, complete airway obstruction •  CO2 level • Hypoventilation, respiratory depression, hyperthermia

CO2 Influence on Circulation •  CO2 in blood (hypoventilation) • Cerebral vasodilation  increase in intracranial pressure (ICP) due to increased blood flow to the brain •  CO2 in blood (hyperventilation) • Cerebral vasoconstriction  decrease in fresh blood flow to brain; decrease in levels of adequate oxygen and glucose negatively affect function of brain

ETCO2 Result Interpretation • Yellow – yes, CO2 is being detected in exhaled breath • Tan – poor perfusion or ventilation status • First evaluate placement of airway device • Continue to trouble shoot • Blue or purple – no CO2 being detected • First evaluate placement of airway device • Continue to trouble shoot

Trouble Shooting Advanced Airway Placement – “DOPE” • D – displacement of tube (i.e.: into esophagus) • Chest rise and fall? • Gastric sounds? • Bilateral breath sounds? • O – obstruction • P – pneumothorax • E – equipment failure • Faulty cuff

Esophageal Detector Device - EDD • A modified bulb syringe • Simple means of evaluating for missed endotracheal intubation • Squeeze bulb, attach to end of endotracheal tube • Bulb re-expands = tube in trachea • Bulb does not re-expand or does so slowly – collapsing sides of esophagus onto tube preventing air from filling EDD – consider esophageal placement

EDD cont’d • Need to interrupt ventilations to use device • Evaluate results of technique used with results of all other steps of confirmation – could be extenuating reason why you get false negatives

Defibrillators • Electrical capacitor that stores energy • Biphasic defibrillators provide waveforms that use less DC energy than monophasic machines • Energy flows in one direction and then reverses • Therefore, possible decrease in tissue damage • Survival rates increase if early CPR provided with prompt defibrillation attempt as soon as possible after collapse

Defibrillation • Early defibrillation critical to survival from sudden cardiac arrest • Most frequent initial rhythm in arrest is VF • Treatment for VF is defib (defibrillation) • Probability of successful defibrillation diminishes over time • VF deteriorates to asystole over time • Check with your vendor to know your biphasic device’s recommended energy settings

Ventricular Fibrillation as Presenting Rhythm • Best chance of survival in public • Early activation of EMS • CPR initiated very soon after collapse • Early application of AED or other defibrillation attempt • Current passes though fibrillating heart to depolarize heart cells to allow them to uniformly repolarize • Allows dominant pacemaker (SA node) to take over electrical control • Goal – resume organized electrical activity

Influences on Success of Defibrillation • Time from onset of VF – shorter time  survival • Condition of myocardium • Less success in presence of hypoxia, acidosis, hypothermia, electrolyte imbalance, drug toxicity • Pad size • Larger pads felt to be more effective and cause less myocardial damage; should not overlap • Ideal size for adults10-13 cm (4 -5 inches) • Ideal size for peds 4.5 cm (roughly 3 inches)

Influences cont’d • Pad / skin interface • Need to  the resistance • Greater the resistance the less energy delivered to the heart and the greater the heat production at the skin surface • Pad contact • Max contact with skin; no air bubbles breaking contact; no pads touching or overlapping • Avoiding placement of pads over bone • Bone is poor conductor of electricity

Pad PlacementOperator Choice • Anterior /posterior • 1 pad over apex of heart, under left breast • 1 pad under left scapula in line with anterior pad • Anterior/anterior (apex) • Anterior pad on right upper sternum just below clavicle • Apex pad below left nipple in anterior axillary line over apex of heart

Pad Placement cont’d • DO NOT place pads • Over sternum – bone poor conductor of electricity • Over pacemaker or AICD – deflects energy; could damage the implanted device • Place at least one inch away from device • Over topical medication patches – deflects energy

Defibrillation • Indications • VF, pulseless VT • Contraindications • Failure to demonstrate one of the above rhythms • Asystole – defibrillation places a patient into asystole for the dominant pacemaker to take over • PEA – electrical activity not a problem; needs mechanical response fixed

Defibrillation • Equipment • Monitor/defibrillator • Defibrillating pads • Example: PadPro • Defibrillation/pacing/cardioversion/monitoring electrodes • Most come with conductive gel already applied in center of pad

Defibrillation Safety • CPR is performed just until the defibrillator is ready • Confirm O2 not blowing across patient’s chest wall – hold away from the patient when not using the BVM • Physically look all around (“nose to toes”) • Clearly yell out “all clear” • Deliver energy • Immediately resume CPR

Return of Spontaneous Circulation ROSC • After 2 minutes of resumed CPR, evaluate the rhythm • If an organized rhythm is viewed on the monitor, THEN check for a pulse • If no pulse, rhythm is PEA • Resume CPR • Adult 1 and 2 man CPR 30:2 • Infant and child 1 man CPR 30:2 • Infant and child 2 man CPR 15:2

Indications to Activate Cooling Protocol Post ROSC • Presumed cardiac arrest • NOT indicated for respiratory or traumatic arrest • Remains unconscious and unresponsive • ROSC present at least 5 minutes • Systolic B/P >90 with or without pressor agent use (i.e.: Dopamine) • Airway has been secured

ROSC Contraindications • Major head trauma or traumatic arrest • Recent major surgery within past 14 days • Systemic infection (i.e.: septic shock) • Coma from other causes • Active bleeding • Isolated respiratory arrest • Hypothermia (34o C/93.2o F) already present

Induction of ROSC • Place ice paks in the axilla, neck and groin • Areas where blood vessels tend to be superficial • Place ice pak over IV site • If patient begins to shiver, contact Medical Control • Anticipate order for Valium to stop the shivering • Shivering will generate heat and therefore increase body temperature

Vasopressor - Dopamine • Stimulates alpha, beta, and dopaminergic receptors based on dose provided • Starting dose 5mcg/kg/min IVPB up to 20 mcg/kg/min • Take patient’s weight and drop last number • Minus 2 from number left • Left with rate to run IVPB in drops per minute • Ex: 150 pounds; drop “0” • 15 – 2 = 13 drops per minute

Dopamine cont’d • Dopaminergic effects at 2 mcg/kg/min • Renal vasodilation to improve blood flow to kidneys • Keep kidneys working, the body keeps working • Beta effects 5 – 10 mcg/kg/min • Increases strength of myocardial contraction – squeeze more blood out of ventricles • Alpha effects at >20 mcg/kg/min • Severe vasoconstriction that diminishes blood flow to all tissues

AED (Automated External Defibrillator) Function • AED’s will • Analyze rhythms • Deliver a shock if indicated • Ventricular fibrillation (VF) • Monomorphic and polymorphic VT if rate and R wave morphology exceed preset values • Will not deliver a synchronized shock • Can indicate loose electrodes / poor electrode contact

AED Use in Pediatrics • Pediatric attenuator used to deliver lower energy doses to children (built into cables with peds pads) • 1-8 year old • Use pediatric pads if available • No attenuator (peds pads)available, use standard AED pads • < 1 year old • Manual defibrillator preferred • If no manual defibrillator, use peds pads with attenuator • No peds pads, use AED pads available

AED Use With CPR • Do NOT interrupt CPR to apply pads • Apply pads while CPR in progress • Do not touch patient during analysis phase • Can provide compressions during charging phase • No O2 flow across patient body during defibrillation attempt • Call and look “ALL CLEAR” prior to each defibrillation attempt • Immediately resume CPR

Transition From AED To Defibrillator • Upon arrival at scene, if AED ready to discharge, utilize AED • Do not interrupt operation of device • During 2 minutes of CPR, can switch from AED use to monitor/defibrillator • Immediately resume CPR after delivery of each defibrillation attempt regardless of equipment used

Synchronized Cardioversion • A controlled form of defibrillation using a lower energy level that interrupts underlying reentrant pathway • Used with organized rhythms and in presence of a pulse • Monitor interprets QRS cycle and energy delivered during R wave • Less vulnerable area of QRS • Downslope of T wave is relative refractory area • Minimal stimulant could generate rhythm into VF

Indications Synchronized Cardioversion • Unstable tachyarrhythmias • SVT • Rapid atrial fibrillation or flutter • Hazard of breaking loose a blood clot in the atria and resulting in a stroke • Ventricular tachycardia Note: polymorphic VT NOT likely to respond to synchronized cardioversion – no defined R wave

Synchronized Cardioversion Procedure • Apply pads • Anterior/anterior or anterior/posterior position • Sedate if possible • This is a painful procedure! • Versed 2 mg IVP/IO; repeated every 2 minutes; max 10 mg (desired effect – sedation!) • Consider pain management • Fentanyl 1 mcg/kg IVP/IN/IO; may repeat in 5 minutes to max of 200 mcg total dose

Sync Procedure cont’d • Activate “sync” button • Verify R wave is being flagged/identified • Choose energy setting starting at the lowest watt setting • 100j, 200j, 300j, 360j • Verify O2 not blowing across chest wall • Look (nose to toes) and call “ALL CLEAR” • Press and hold sync buttons until energy discharged • Momentary delay waiting to identify the R wave

Sync Procedure cont’d • If synchronized cardioversion needs to be repeated, need to reset the “sync” button • Safety that machine will default to defibrillation mode after every discharge of energy • If VF occurs, verify sync mode is off and defibrillate patient without delay

Transcutaneous Pacemaker - TCP • Electrical cardiac pacing across the skin • TCP is a painful non-invasive procedure so sedation will most likely be necessary • Indications • Symptomatic bradycardia • Hypotensive • Hypoperfusing • Evaluate level of consciousness and B/P for most reliable indicators of patient condition/stability

TCP Procedure • Apply pads • (-) over apex of heart, anterior chest wall • (+) mid upper back below left scapula • Set desired heart rate (80) • Confirm sensitivity at auto/demand • Begin mA current at 0 • Turn pacer on

EMS Equipment Review