Altered Mental Status Medication Review Lung Sounds MAD Device ECRN Module I 2010 CE Condell EMS System Prepared by Sharon Hopkins, RN, BSN, EMT-P.

Altered Mental StatusAltered Mental StatusMedication ReviewMedication Review

Lung SoundsLung SoundsMAD DeviceMAD Device

ECRN Module I ECRN Module I 2010 CE2010 CE

Condell EMS SystemCondell EMS System

Prepared by Sharon Hopkins, RN, BSN, EMT-PPrepared by Sharon Hopkins, RN, BSN, EMT-P

ObjectivesObjectives

Upon successful completion of this module, the Upon successful completion of this module, the ECRN will be able to:ECRN will be able to: Describe elements of normal mental status.Describe elements of normal mental status. Describe components of the neurological Describe components of the neurological

examination.examination. List the three components of the Glasgow List the three components of the Glasgow

coma scale.coma scale. Calculate the GCS.Calculate the GCS. List common causes of an altered mental List common causes of an altered mental

status.status.

Objectives cont’dObjectives cont’d

Review Cincinnati Stoke ScaleReview Cincinnati Stoke Scale Describe the FAST conceptDescribe the FAST concept Review Region X SOP Altered Mental StatusReview Region X SOP Altered Mental Status Explain the differences between the adult and Explain the differences between the adult and

the pediatric airway.the pediatric airway. Describe the assessment of the airway and Describe the assessment of the airway and

respiratory system.respiratory system. Describe the various lung sounds auscultated Describe the various lung sounds auscultated

during assessment.during assessment.

Objectives cont’dObjectives cont’d

Discuss the methods for measuring oxygen Discuss the methods for measuring oxygen and carbon dioxide in the blood in the and carbon dioxide in the blood in the prehospital setting.prehospital setting.

Identify pre-hospital indications, Identify pre-hospital indications, contraindications, dosing, side effects, and contraindications, dosing, side effects, and special considerations of Dextrose, special considerations of Dextrose, Glucagon, Narcan, Albuterol, Epinephrine Glucagon, Narcan, Albuterol, Epinephrine 1:1000, Benadryl, Lasix, and Morphine.1:1000, Benadryl, Lasix, and Morphine.

Objectives cont’dObjectives cont’d

Describe the indications, contraindications, Describe the indications, contraindications, dosing, side effects, and special dosing, side effects, and special considerations for administering Narcan via considerations for administering Narcan via the MAD tool.the MAD tool.

Describe the MAD tool and the procedure for Describe the MAD tool and the procedure for using the MAD tool.using the MAD tool.

Describe the indications, contraindications, Describe the indications, contraindications, complications, and the process for performing complications, and the process for performing a cricothyrotomy in the field.a cricothyrotomy in the field.

Normal Mental StatusNormal Mental Status

ConsciousnessConsciousness Person is fully responsive to stimuli and Person is fully responsive to stimuli and

demonstrates awareness of the demonstrates awareness of the environmentenvironment

Altered level of consciousnessAltered level of consciousness Some form of dysfunction or interruption Some form of dysfunction or interruption

in the central nervous systemin the central nervous system

Normal Mental StatusNormal Mental Status

Patient is awakePatient is awake Patient is alert – aware of surroundingsPatient is alert – aware of surroundings Patient is oriented to person, place, & timePatient is oriented to person, place, & time Patient is cooperativePatient is cooperative Patient carries on normal conversationPatient carries on normal conversation Patient able to follow/obey commands Patient able to follow/obey commands Gait is even and steadyGait is even and steady

Altered Level of Altered Level of ConsciousnessConsciousness

Hallmark sign of Hallmark sign of central nervous central nervous system injury or system injury or

illnessillness

Did You Know?Did You Know?

When perfusion is declining, the When perfusion is declining, the firstfirst indicator is a indicator is a changing level of changing level of consciousnessconsciousness

The The lastlast indicator is a indicator is a falling blood pressurefalling blood pressure

Assessing Mental Status - AVPUAssessing Mental Status - AVPU

A – awakeA – awake V – responds to verbal stimuliV – responds to verbal stimuli P – responds to painful stimuliP – responds to painful stimuli U- unresponsiveU- unresponsive

A – “Awake”A – “Awake”

Patient is awake, alert and aware of Patient is awake, alert and aware of surroundingssurroundings

OROR Patient may be awake but confusedPatient may be awake but confused

Report what the patient is oriented toReport what the patient is oriented to

• ““Oriented to person but not place or Oriented to person but not place or time”time”

Key is watching for a change in level of Key is watching for a change in level of consciousness from the baseline takenconsciousness from the baseline taken

V – Verbal ResponseV – Verbal Response

This would need to be evaluated prior to This would need to be evaluated prior to touching the “unconscious” patienttouching the “unconscious” patient

ProblemProblem: If trauma is involved, need to : If trauma is involved, need to manually control the C-spine before manually control the C-spine before causing the patient any movement of causing the patient any movement of the c-spinethe c-spine

If possible, call the patient’s name to If possible, call the patient’s name to check for response to verbal stimuli check for response to verbal stimuli prior to making physical contactprior to making physical contact

P – Painful ResponseP – Painful Response

Does not necessarily mean you have to Does not necessarily mean you have to perform a painful task to check for responseperform a painful task to check for response Start with simple tactile contact – touchStart with simple tactile contact – touch Add deeper stimulation if neededAdd deeper stimulation if needed

• Sternal rubSternal rub• Pinch of thumb web spacePinch of thumb web space• Trapezius muscle squeeze (near neck)Trapezius muscle squeeze (near neck)

Do not cause so much trauma as to leave Do not cause so much trauma as to leave marks/bruisesmarks/bruises

Observe for Observe for somesome kind of response with muscles kind of response with muscles

Patient ResponsePatient Response

Patient response can include:Patient response can include: Opening of eyelids even brieflyOpening of eyelids even briefly Fluttering of eyelidsFluttering of eyelids Wrinkling of browsWrinkling of brows

Most important is looking for Most important is looking for changeschanges in in the patient’s response from one the patient’s response from one evaluation/assessment to the nextevaluation/assessment to the next

U - UnresponsiveU - Unresponsive

The patient has NO response at allThe patient has NO response at all No moaningNo moaning No muscle twitch at allNo muscle twitch at all

• No eyelid flutterNo eyelid flutter• No wrinkling of the eyebrowNo wrinkling of the eyebrow

Muscles are flaccid with absolutely no Muscles are flaccid with absolutely no response regardless of stimuliresponse regardless of stimuli

Neurological Exam In the FieldNeurological Exam In the Field

AVPU – what is level of consciousness?AVPU – what is level of consciousness? Pupillary responsePupillary response Movement of distal extremitiesMovement of distal extremities

Wiggling fingers and toesWiggling fingers and toes

Sensation of distal extremitiesSensation of distal extremities Ability to feel contact with fingers and toesAbility to feel contact with fingers and toes

GCSGCS <<10 or deteriorating mental status patient is 10 or deteriorating mental status patient is

considered critical and categorized as Category I considered critical and categorized as Category I traumatrauma

Glasgow Coma Scale - GCSGlasgow Coma Scale - GCS

The best score possible is givenThe best score possible is given More important is watching the trend than More important is watching the trend than

relying on any one scorerelying on any one score Objective toolObjective tool

All using the tool on the same patient should get All using the tool on the same patient should get the same scorethe same score

EvaluateEvaluate Best eye openingBest eye opening Best verbal responseBest verbal response Best motor responseBest motor response

GCS – Eye OpeningGCS – Eye Opening

4 – Spontaneous; patient’s eyes are open4 – Spontaneous; patient’s eyes are open Does not have to be focusingDoes not have to be focusing

3 – Eyes open or motion is made to verbal 3 – Eyes open or motion is made to verbal

stimulistimuli Start with soft voice, may have to yell at patient to Start with soft voice, may have to yell at patient to

open eyesopen eyes

2 – Eyes open with tactile or painful stimuli2 – Eyes open with tactile or painful stimuli Start with gentle touch; may need to add more Start with gentle touch; may need to add more

intense stimuliintense stimuli

1 – No eye opening; no muscle motion at all1 – No eye opening; no muscle motion at all

GCS – Verbal ResponseGCS – Verbal Response

5 – Oriented to person, place, and time5 – Oriented to person, place, and time 4 – Pleasantly confused4 – Pleasantly confused 3 – Inappropriate words3 – Inappropriate words

You can understand the word(s) spoken You can understand the word(s) spoken but they are not within context but they are not within context

2 – Incomprehensible words – sounds2 – Incomprehensible words – sounds No intelligible word understood; moans and No intelligible word understood; moans and

groans; makes noisesgroans; makes noises 1 – Silent; no noise is made at all1 – Silent; no noise is made at all

GCS – Motor ResponseGCS – Motor Response

6 – Obeys commands6 – Obeys commands 5 – Localizes pain / purposeful movement5 – Localizes pain / purposeful movement

Can push you away or grab at the noxious Can push you away or grab at the noxious stimuli (IV, collar, bandaging, your hands)stimuli (IV, collar, bandaging, your hands)

4 – Withdrawal4 – Withdrawal No longer localizing, just withdraws/pulls away No longer localizing, just withdraws/pulls away

to get away from annoying/painful stimuli (IV, to get away from annoying/painful stimuli (IV, collar, bandaging, your hands)collar, bandaging, your hands)

Motor cont’dMotor cont’d

3 – Flexion to pain3 – Flexion to pain Arms flex/bend slowly toward center of chest Arms flex/bend slowly toward center of chest

when any stimuli appliedwhen any stimuli applied 2 – Extension to pain2 – Extension to pain

Arms slowly extend and curl inward and legs Arms slowly extend and curl inward and legs straighten when any stimuli appliedstraighten when any stimuli applied

1 – No movement at all1 – No movement at all

GCS ResultsGCS Results

Score range 3 – 15Score range 3 – 15 Minor head injury – 13 – 15Minor head injury – 13 – 15 Moderate head injury – 9 – 12Moderate head injury – 9 – 12 Severe head injury (coma) - Severe head injury (coma) - <<88

Significant mortality riskSignificant mortality risk Consider intubation or other means to secure Consider intubation or other means to secure

the airwaythe airway

GCS PracticeGCS Practice

Read the following case scenariosRead the following case scenarios Determine the best eye opening, verbal Determine the best eye opening, verbal

response, motor responseresponse, motor response When the response is asymmetrical, award When the response is asymmetrical, award

the highest points possiblethe highest points possible Don’t guess or assume what you think they Don’t guess or assume what you think they

really can doreally can do Award points for what is performedAward points for what is performed Be objectiveBe objective

Note: Answers follow the practice slideNote: Answers follow the practice slide

GCS Case #1GCS Case #1

Patient lying in the bed (no trauma), eyes Patient lying in the bed (no trauma), eyes are closedare closed

You need to yell the patient’s name and You need to yell the patient’s name and then the eyelids flickerthen the eyelids flicker

They are mumblingThey are mumbling They are grabbing at your hands and They are grabbing at your hands and

pushing you away. They have pulled out pushing you away. They have pulled out the IV.the IV.

GCS Case #1 ScoreGCS Case #1 Score Eye opening – 3Eye opening – 3

Responded to loud voiceResponded to loud voice Verbal response – 2Verbal response – 2

Mumbling is incomprehensible words/soundsMumbling is incomprehensible words/sounds Motor response – 5Motor response – 5

Patient can recognize (localize) what feels Patient can recognize (localize) what feels obnoxious and what he wants to stop so they obnoxious and what he wants to stop so they are grabbing at you and pulling at equipmentare grabbing at you and pulling at equipment

Total GCS - 10Total GCS - 10

GCS Case #2GCS Case #2

Patient is lying in the street watching you Patient is lying in the street watching you approachapproach

They mumble as you talk to themThey mumble as you talk to them They are grabbing at your hands and They are grabbing at your hands and

pushing you awaypushing you away

GCS Case #2 ScoreGCS Case #2 Score

Eye opening – 4Eye opening – 4 Spontaneous; doesn’t necessarily indicate Spontaneous; doesn’t necessarily indicate

focusingfocusing Verbal response – 2Verbal response – 2

Mumbling, moaning, groaningMumbling, moaning, groaning Motor response – 5Motor response – 5

Purposeful movement by grabbing at what Purposeful movement by grabbing at what the patient perceives as noxious stimulithe patient perceives as noxious stimuli

Total GCS - 11Total GCS - 11

GCS Case #3GCS Case #3

Patient watches your approach and Patient watches your approach and acknowledges your presenceacknowledges your presence

Patient answers most questions and thinks Patient answers most questions and thinks you are their relative come to visityou are their relative come to visit

Patient able to move left arm to command Patient able to move left arm to command but not able to move right arm (new onset but not able to move right arm (new onset – possible stroke)– possible stroke)

GCS Case #3 ScoreGCS Case #3 Score

Eye opening – 4Eye opening – 4 SpontaneousSpontaneous

Verbal response – 4Verbal response – 4 Pleasantly confusedPleasantly confused

Motor response – 6Motor response – 6 Highest possible score based on the arm that Highest possible score based on the arm that

can and does movecan and does move Total GCS - 14Total GCS - 14

GCS Case #4GCS Case #4

Child’s eyelids flicker when deformed Child’s eyelids flicker when deformed extremity is manipulatedextremity is manipulated

Child moans out when painful areas are Child moans out when painful areas are manipulatedmanipulated

Child pulls away when touched and tries to Child pulls away when touched and tries to turn away from EMSturn away from EMS

GCS Case #4 ScoreGCS Case #4 Score Eye opening – 2Eye opening – 2

Response to painful stimuliResponse to painful stimuli Verbal response – 2Verbal response – 2

Moans and groans are incomprehensible words Moans and groans are incomprehensible words / sounds / sounds

Motor response – 4Motor response – 4 Withdrawing from what is sensed as painful Withdrawing from what is sensed as painful

stimulistimuli Flexion would be slow flexing of arms toward Flexion would be slow flexing of arms toward

center of chest – this patient’s response is not center of chest – this patient’s response is not flexionflexion

Total GCS – 8 (Total GCS – 8 (Protect airway; consider intubation)Protect airway; consider intubation)

GCS Case #5GCS Case #5

Patient’s eyes remain closed; no eyelid Patient’s eyes remain closed; no eyelid movement at allmovement at all

There are no sounds heard from the There are no sounds heard from the patientpatient

The patient straightens their arms, twists The patient straightens their arms, twists their wrists, arches their back, and their wrists, arches their back, and straightens their legs when stimulatedstraightens their legs when stimulated

GCS Case #5 ScoreGCS Case #5 Score Eye opening – 1 (no response)Eye opening – 1 (no response) Verbal response – 1 (no response)Verbal response – 1 (no response) Motor response – 2Motor response – 2

Abnormal extensionAbnormal extension The worse level of response prior to no The worse level of response prior to no

response at allresponse at all Total GCS – 4Total GCS – 4

Patient is critical; Category I Patient is critical; Category I Patient usually needs some airway Patient usually needs some airway

interventionintervention

Common Causes of Altered Mental Common Causes of Altered Mental StatusStatus

A – acidosis, alcoholA – acidosis, alcohol E – EpilepsyE – Epilepsy I – Infection (brain, sepsis)I – Infection (brain, sepsis) O – OverdoseO – Overdose U – Uremia (kidney failure)U – Uremia (kidney failure) T – Trauma, tumor, toxinsT – Trauma, tumor, toxins I – Insulin – hypo or hyperglycemiaI – Insulin – hypo or hyperglycemia P – Psychosis, poisonP – Psychosis, poison S – Stroke, seizureS – Stroke, seizure

Initial Patient AssessmentInitial Patient Assessment

AirwayAirway Open or obstructedOpen or obstructed Maneuvers needed to openManeuvers needed to open

• Head tilt / chin liftHead tilt / chin lift• With trauma, modified jaw thrustWith trauma, modified jaw thrust

BreathingBreathing QualityQuality Quantity (eyeball assessment at this time)Quantity (eyeball assessment at this time)

Initial Assessment cont’dInitial Assessment cont’d

CirculationCirculation QualityQuality Quantity (don’t count; get estimate of Quantity (don’t count; get estimate of

range)range) Disability – need to obtain baselinesDisability – need to obtain baselines

AVPUAVPU GCSGCS

Expose to examineExpose to examine Can’t evaluate or fix what you can’t seeCan’t evaluate or fix what you can’t see

Assessment ToolsAssessment Tools

AVPUAVPU AAlert (interpreted as an awake patient)lert (interpreted as an awake patient) Responds to Responds to vverbal stimulierbal stimuli Responds to Responds to ppainful stimuliainful stimuli UUnresponsivenresponsive

Assessment ToolsAssessment Tools

GCS GCS Best eye opening response Best eye opening response Best verbal responseBest verbal response Best motor responseBest motor response

Scores range from the lowest of 3 to Scores range from the lowest of 3 to highest of 15highest of 15

Obtain and document GCS on all patient Obtain and document GCS on all patient callscalls

Cincinnati Stroke ScaleCincinnati Stroke Scale

Obtain for suspicion of TIA or strokeObtain for suspicion of TIA or stroke Evaluate for facial droopEvaluate for facial droop

Check the patient’s symmetry during a Check the patient’s symmetry during a broad, big smile (teeth showing)broad, big smile (teeth showing)

Evaluate for arm driftEvaluate for arm drift Check for weakness in holding arms Check for weakness in holding arms

outstretched, palms up, for 10 secondsoutstretched, palms up, for 10 seconds Evaluate for clear speechEvaluate for clear speech

Have patient repeat words listening for Have patient repeat words listening for clear speech patternsclear speech patterns

Airway Protection and the Stroke Airway Protection and the Stroke PatientPatient

Crucial - high mortality rate for aspirationCrucial - high mortality rate for aspiration Is airway patent and can patient protect Is airway patent and can patient protect

their own airway?their own airway? Check if patient is able to handle & swallow Check if patient is able to handle & swallow

own salivaown saliva• Detailed/involved swallow study done in-hospitalDetailed/involved swallow study done in-hospital

Patient speaks in clear unobstructed voicePatient speaks in clear unobstructed voice Interventions to considerInterventions to consider

Have suction on and readyHave suction on and ready Ability to quickly turn patient onto their sideAbility to quickly turn patient onto their side

FAST - Public FAST - Public Educational Educational

ToolTool

Tool Tool developed by developed by organizations organizations for public for public recognition of recognition of stroke and to stroke and to encourage encourage FAST actionFAST action

Region X SOP – Region X SOP – Altered Mental StatusAltered Mental Status

Consider etiologyConsider etiology If cause of problem can be identified, then If cause of problem can be identified, then

interventions can be focusedinterventions can be focused• Diabetes – check blood sugarDiabetes – check blood sugar• Drug overdose – what are the Drug overdose – what are the

environmental cluesenvironmental clues• Poisoning – environmental evidence Poisoning – environmental evidence

aroundaround• Alcohol related – environmental Alcohol related – environmental

evidence; use your noseevidence; use your nose

SOP – Altered Mental StatusSOP – Altered Mental Status

Maintain airway Maintain airway Patency extremely importantPatency extremely important

Evaluate rate and qualityEvaluate rate and quality If respirations inadequate, ventilateIf respirations inadequate, ventilate

• 1 breath every 5-6 seconds all patients – 1 breath every 5-6 seconds all patients – infancy to elderlyinfancy to elderly

Intubate as necessaryIntubate as necessary Use C-spine precautions as indicatedUse C-spine precautions as indicated

If any doubt, err on side of extra precautionsIf any doubt, err on side of extra precautions Provide Routine Medical CareProvide Routine Medical Care

IV – OIV – O22 - monitor - monitor

SOP – Altered Mental StatusSOP – Altered Mental Status Obtain blood glucose levelObtain blood glucose level

If <60 – treatIf <60 – treat• Adult - Dextrose 50% 50 ml IVPAdult - Dextrose 50% 50 ml IVP• Child 1 – 15 – Dextrose 25% 2 ml/kgChild 1 – 15 – Dextrose 25% 2 ml/kg• Infant <1 – Dextrose 12.5% 4 ml/kgInfant <1 – Dextrose 12.5% 4 ml/kg

Dilute 1:1 ratio D 25% with normal Dilute 1:1 ratio D 25% with normal salinesaline

Equal amounts of product make 1:1 Equal amounts of product make 1:1 dilution (Dextrose and normal saline)dilution (Dextrose and normal saline)

Treating Altered Mental StatusTreating Altered Mental Status In absence of IV accessIn absence of IV access

• Adult – Glucagon 1 unit (1 ml) IMAdult – Glucagon 1 unit (1 ml) IM• Pediatrics Pediatrics < < 15 – Glucagon 0.1 mg/kg IM15 – Glucagon 0.1 mg/kg IM

Max dose of 1 mgMax dose of 1 mg

Practice math: 44 pound child with no IV accessPractice math: 44 pound child with no IV access• How many kg? How many kg?

44# 44# 2.2 = 20 kg 2.2 = 20 kg• 20 kg x 0.1mg/kg = 2 mg20 kg x 0.1mg/kg = 2 mg• How much Glucagon do you give?How much Glucagon do you give?

Max of 1 mg (max drugs at adult dose) Max of 1 mg (max drugs at adult dose)

Altered Mental Status cont’dAltered Mental Status cont’d If patient not alert, respirations decreased, or If patient not alert, respirations decreased, or

narcotic overdose suspected:narcotic overdose suspected: Narcan 2mg IN/IVP/IONarcan 2mg IN/IVP/IO

• Repeat every 5 minutes as needed until Repeat every 5 minutes as needed until desired effectdesired effect

Quality of respirations have improvedQuality of respirations have improved Don’t need patient to be 15 on GCSDon’t need patient to be 15 on GCS Don’t need patient awake necessarilyDon’t need patient awake necessarily

• Maximum total dose 10 mgMaximum total dose 10 mg TransportTransport

Altered Mental Status cont’dAltered Mental Status cont’d

Note: Note: Attempt to identify substances involvedAttempt to identify substances involved If not a safety hazard, obtain and transport If not a safety hazard, obtain and transport

substance container with the patientsubstance container with the patient Consider use of restraints prior to Consider use of restraints prior to

administration of Narcanadministration of Narcan• Patient may become violent when level Patient may become violent when level

of consciousness improvesof consciousness improves

Adult Airway Adult Airway Pediatric airwayPediatric airway

Note funnel shaping of pediatric airway Note funnel shaping of pediatric airway

Notice Difference in Tongue SizeNotice Difference in Tongue Size Adult airwayAdult airway Pediatric airwayPediatric airway

tongue

Pediatric airway DifferencesPediatric airway Differences Jaw smallerJaw smaller Teeth softer and more fragileTeeth softer and more fragile Tongue relatively largerTongue relatively larger

Potential to produce more obstructionPotential to produce more obstruction Epilgottis floppier and rounderEpilgottis floppier and rounder

Recommend straight Miller blade over curved Macintosh Recommend straight Miller blade over curved Macintosh for intubationfor intubation

Larynx more superior & anteriorLarynx more superior & anterior Higher and more forwardHigher and more forward Funnel shaped due to underdeveloped cricoid cartilageFunnel shaped due to underdeveloped cricoid cartilage

• Under age 10 cricoid cartilage narrowest part of airwayUnder age 10 cricoid cartilage narrowest part of airway Ribs and cartilage softer and more pliableRibs and cartilage softer and more pliable

Children rely on diaphragm muscle for breathingChildren rely on diaphragm muscle for breathing

Airway AssessmentAirway Assessment

InspectionInspection Begin as you are approaching the patientBegin as you are approaching the patient

AuscultationAuscultation Listen for audible sounds, then use Listen for audible sounds, then use

stethoscopestethoscope PalpationPalpation

Can gather a lot of information through the Can gather a lot of information through the art of touchart of touch

Assessment of AirwayAssessment of Airway Initial assessmentInitial assessment

ABC’sABC’s• Airway open?Airway open?

Fully open with adequate air exchange?Fully open with adequate air exchange? Partially or fully obstructed with poor air exchange?Partially or fully obstructed with poor air exchange?

• Are they breathing?Are they breathing? Look for chest rise and fallLook for chest rise and fall Listen for air movementListen for air movement Feel for air movementFeel for air movement

• Do they have a pulse?Do they have a pulse?

Airway Assessment cont’dAirway Assessment cont’d

InspectionInspection Evaluate adequacy of breathingEvaluate adequacy of breathing Note any signs of traumaNote any signs of trauma Assess skin colorAssess skin color

• Paleness and diaphoresis due to sympathetic Paleness and diaphoresis due to sympathetic stimulation in early respiratory compromisestimulation in early respiratory compromise

• Cyanosis if deoxygenated (LATE SIGN!!!)Cyanosis if deoxygenated (LATE SIGN!!!) Patient positioningPatient positioning

• Tripod – leaning forward (CHF? Asthma?)Tripod – leaning forward (CHF? Asthma?)• Orthopnea – can’t lay down (CHF? Asthma?)Orthopnea – can’t lay down (CHF? Asthma?)

Inspection cont’dInspection cont’d

Observe for dyspneaObserve for dyspnea• May cause or be caused by hypoxiaMay cause or be caused by hypoxia• Prolonged dyspnea can lead to anoxia Prolonged dyspnea can lead to anoxia

(absence of oxygen)(absence of oxygen)• Is dyspnea a new onset or perhaps chronic Is dyspnea a new onset or perhaps chronic

in the patient with long standing COPDin the patient with long standing COPD

Abnormal Respiratory PatternsAbnormal Respiratory Patterns

Kussmaul’sKussmaul’s Deep, slow or rapid, gasping breathingDeep, slow or rapid, gasping breathing Commonly found in diabetic ketoacidosis in Commonly found in diabetic ketoacidosis in

attempt to blow off excess COattempt to blow off excess CO22 (acid) (acid) Cheyne –StokesCheyne –Stokes

Progressively deeper, faster breathing Progressively deeper, faster breathing alternating with gradually shallow and slower alternating with gradually shallow and slower breathingbreathing

Indicates brainstem injuryIndicates brainstem injury

Respiratory Patterns cont’dRespiratory Patterns cont’d

Biot’sBiot’s Irregular pattern of rate and depth with sudden, Irregular pattern of rate and depth with sudden,

periodic episodes of apneaperiodic episodes of apnea Indicates increased intracranial pressureIndicates increased intracranial pressure

Central neurogenic hyperventilationCentral neurogenic hyperventilation Deep, rapid respirationsDeep, rapid respirations Indicates increased intracranial pressureIndicates increased intracranial pressure

Agonal Agonal Shallow, slow, or infrequent breathingShallow, slow, or infrequent breathing Indicates brain anoxia, impending deathIndicates brain anoxia, impending death

Respiratory Assessment cont’dRespiratory Assessment cont’d

AuscultationAuscultation Listen 1Listen 1stst audibly for any abnormal sounds audibly for any abnormal sounds Have patient cough to clear loose secretionsHave patient cough to clear loose secretions Then listen with stethoscopeThen listen with stethoscope

• Right and left apex (under clavicles)Right and left apex (under clavicles)• Right and left bases (8Right and left bases (8thth – 9 – 9thth intercostal intercostal

space, midclavicular)space, midclavicular)• Right and left lower thoracic back or right Right and left lower thoracic back or right

and left midaxillary line (lateral chest wall)and left midaxillary line (lateral chest wall)

Auscultation cont’dAuscultation cont’d Posterior aspect preferable to anterior surfacePosterior aspect preferable to anterior surface

Less tissue massLess tissue mass Lungs closer to the surfaceLungs closer to the surface Less interference with heart soundsLess interference with heart sounds

Anterior and lateral sections of the chest are Anterior and lateral sections of the chest are more accessible especially in supine patientsmore accessible especially in supine patients

Evaluate for symmetrical equalityEvaluate for symmetrical equality Keep stethoscope in place long enough to hear Keep stethoscope in place long enough to hear

end of exhalationend of exhalation Many abnormal sounds heard first at end of Many abnormal sounds heard first at end of

exhalationexhalation

Abnormal Lung SoundsAbnormal Lung Sounds SnoringSnoring

Partial obstruction of upper airway, usually Partial obstruction of upper airway, usually from tonguefrom tongue

Patient needs airway repositionedPatient needs airway repositioned GurglingGurgling

Accumulation of fluids (blood, vomitus, Accumulation of fluids (blood, vomitus, other secretions) in upper airwayother secretions) in upper airway

StridorStridor Harsh, high-pitched sound heard on Harsh, high-pitched sound heard on

inhalation; usually indicates laryngeal inhalation; usually indicates laryngeal edema or constrictionedema or constriction

Lung Sounds cont’dLung Sounds cont’d

WheezingWheezing Musical, squeaking, or whistling sound Musical, squeaking, or whistling sound

heard in inspiration and/or exhalationheard in inspiration and/or exhalation Indicates bronchiolar constrictionIndicates bronchiolar constriction

• Asthma, COPDAsthma, COPD

QuietQuiet Diminished or absent breath sounds Diminished or absent breath sounds

ominousominous Indicates serious problem with airway, Indicates serious problem with airway,

breathing, or bothbreathing, or both

Lung Sounds cont’dLung Sounds cont’d Crackles (rales)Crackles (rales)

Fine, bubbling sound heard on inspiration, sounds like Fine, bubbling sound heard on inspiration, sounds like velcro rippingvelcro ripping

Indicates fluid in smaller airwaysIndicates fluid in smaller airways• CHFCHF• PneumoniaPneumonia

Gas exchange may be compromisedGas exchange may be compromised RhonchiRhonchi

Course, rattling noise heard on inspirationCourse, rattling noise heard on inspiration Associated with inflammation, mucus, or fluid in bronchiolesAssociated with inflammation, mucus, or fluid in bronchioles Gas exchange may be compromisedGas exchange may be compromised

• Chronic bronchitisChronic bronchitis

Airway AssessmentAirway Assessment

PalpationPalpation Often forgotten assessment toolOften forgotten assessment tool Palpate chest wall forPalpate chest wall for

• TendernessTenderness• SymmetrySymmetry• Abnormal motionAbnormal motion• Crepitus (bone crunching)Crepitus (bone crunching)• Subcutaneous emphysemaSubcutaneous emphysema

Air leakage into tissueAir leakage into tissue

Pulse OximetryPulse Oximetry

Measures hemoglobin oxygen Measures hemoglobin oxygen saturation in peripheral tissuesaturation in peripheral tissue

Non-invasive means to measure Non-invasive means to measure effectiveness of oxygenation and effectiveness of oxygenation and ventilationventilation

Continually reflects changes Continually reflects changes May detect changes faster than May detect changes faster than

assessment of vital signsassessment of vital signs

Pulse OximetryPulse Oximetry Place probe over a peripheral capillary bedPlace probe over a peripheral capillary bed

Fingertip, toe, earlobeFingertip, toe, earlobe 2 sensors take measurements of light 2 sensors take measurements of light

reaching them from 2 light emitting diodes reaching them from 2 light emitting diodes Oximeter calculates ratio of light receivedOximeter calculates ratio of light received

• Influenced by amount of oxygenated Influenced by amount of oxygenated versus deoxygenated hemoglobinversus deoxygenated hemoglobin

SpOSpO22 determined determined

Suggested SpOSuggested SpO22 Results Results

95 – 99% - normal95 – 99% - normal 91 -94% - mild hypoxia91 -94% - mild hypoxia

Perform additional evaluationPerform additional evaluation Administer supplemental oxygenAdminister supplemental oxygen

86 – 91% - moderate hypoxia86 – 91% - moderate hypoxia Perform additional evaluationPerform additional evaluation Administer 100% supplemental oxygenAdminister 100% supplemental oxygen

<85% - severe hypoxia<85% - severe hypoxia Immediate intervention requiredImmediate intervention required

SpOSpO22 Error Results Error Results Current equipment more accurate; less error Current equipment more accurate; less error

readingsreadings False readings possibleFalse readings possible

Carbon monoxide exposure – false highCarbon monoxide exposure – false high High-intensity lighting near sensorsHigh-intensity lighting near sensors Hemoglobin abnormalitiesHemoglobin abnormalities Absent peripheral pulsesAbsent peripheral pulses Hypovolemia; severe anemiaHypovolemia; severe anemia

• SpOSpO22 may be normal but the amount of may be normal but the amount of

hemoglobin available is lowhemoglobin available is low

Coordinate readings with patient assessmentCoordinate readings with patient assessment

CapnographyCapnography

Graphic recording or display of Graphic recording or display of measurement of expired COmeasurement of expired CO22 over time over time

End-tidal COEnd-tidal CO22 (ETCO (ETCO22) – measurement of ) – measurement of

COCO22 concentration at end of expiration concentration at end of expiration

Provides information Provides information Systemic metabolism (production of COSystemic metabolism (production of CO22)) CirculationCirculation VentilationVentilation

How Does COHow Does CO22 Circulate? Circulate?

COCO22 is normal end product of is normal end product of metabolismmetabolism

Transported by venous system to right Transported by venous system to right side of heartside of heart

Pumped from right ventricle Pumped from right ventricle pulmonary artery pulmonary artery lungs and lungs and pulmonary capillariespulmonary capillaries

Diffuses into alveoliDiffuses into alveoli Removed from body via exhalationRemoved from body via exhalation

Poor Perfusion StatesPoor Perfusion States

Shock, cardiac arrest, pulmonary Shock, cardiac arrest, pulmonary embolism, bronchospasm, incomplete embolism, bronchospasm, incomplete airway obstruction (ie: mucous airway obstruction (ie: mucous plugging)plugging) Perfusion decreasedPerfusion decreased ETCOETCO22 will reflect pulmonary blood will reflect pulmonary blood

flow and cardiac outputflow and cardiac output Will not reflect ventilation in poor Will not reflect ventilation in poor

perfusion statesperfusion states

End Tidal COEnd Tidal CO22 Detector Detector

Contains pH sensitive chemically Contains pH sensitive chemically impregnated paper to estimate ETCOimpregnated paper to estimate ETCO22 levellevel

Color change is reversibleColor change is reversible Will reflect changes breath to breathWill reflect changes breath to breath Paper will be unreliable if Paper will be unreliable if

contaminated with acidic contaminated with acidic drugs or gastric contentsdrugs or gastric contents

Tool placed near elbow on Tool placed near elbow on BVMBVM

Interpreting the ETCOInterpreting the ETCO22

Yellow – indicates measured COYellow – indicates measured CO22 being being exhaledexhaled Evaluate after 6 breathsEvaluate after 6 breaths

Tan – low levels of COTan – low levels of CO22 measured measured Misplaced tube or poor carbon dioxide Misplaced tube or poor carbon dioxide

productionproduction• Evaluate tube positioningEvaluate tube positioning• Evaluate patient perfusionEvaluate patient perfusion

Blue or purple – no COBlue or purple – no CO22 being measured being measured Suspect unsuccessful intubationSuspect unsuccessful intubation

ETCOETCO22

ApplicationsApplications Verify placement of endotracheal tubeVerify placement of endotracheal tube Assess effectiveness of CPR Assess effectiveness of CPR

• COCO22 levels fall abruptly at onset of levels fall abruptly at onset of cardiac arrestcardiac arrest

• COCO22 levels begin to rise with effective levels begin to rise with effective CPRCPR

Medication ReviewMedication Review

(Information based on Region X EMS usage)(Information based on Region X EMS usage)

IndicationIndicationContraindicationContraindication

DosingDosingSide effects Side effects

Special considerationsSpecial considerations

DextroseDextrose

Carbohydrate used to raise the sugar levelCarbohydrate used to raise the sugar level No contraindication in suspected hypoglycemiaNo contraindication in suspected hypoglycemia Administered when the blood sugar level is less Administered when the blood sugar level is less

than 60 than 60 Dose based on ageDose based on age

Adult 16 and over – 50% 50 ml slow IVPAdult 16 and over – 50% 50 ml slow IVP 1 – 15 – D 25% - 2 ml / kg slow IVP1 – 15 – D 25% - 2 ml / kg slow IVP <1 – D 12.5% - 4 ml / kg slow IVP<1 – D 12.5% - 4 ml / kg slow IVP

• Mix 1:1 dilution with D25% and normal Mix 1:1 dilution with D25% and normal salinesaline

Dextrose cont’dDextrose cont’d

Local vein irritation may occur Local vein irritation may occur especially when small veins are usedespecially when small veins are used

If glucagon was administered and then If glucagon was administered and then an IV site is secured, retest the blood an IV site is secured, retest the blood sugar levelsugar level If blood glucose remains <60 and patient If blood glucose remains <60 and patient

condition not improved, administer condition not improved, administer DextroseDextrose

GlucagonGlucagon

Hormone to stimulate breakdown of Hormone to stimulate breakdown of glycogen (stored form of glucose)glycogen (stored form of glucose)

Patient may have an allergic reaction if they Patient may have an allergic reaction if they have allergies to proteinshave allergies to proteins

Adult dosing – 1 mg (1 unit) IMAdult dosing – 1 mg (1 unit) IM Pediatric dosing up to 15 years old – Pediatric dosing up to 15 years old –

0.1 mg/kg (max dose 1 mg – 1 unit)0.1 mg/kg (max dose 1 mg – 1 unit)

Glucagon cont’dGlucagon cont’d

Observe for nausea and vomitingObserve for nausea and vomiting May take up to 20 minutes for Glucagon May take up to 20 minutes for Glucagon

to be effectiveto be effective Will not have any effect if there are no Will not have any effect if there are no

stores of glycogen in the liverstores of glycogen in the liver Patient requires rapid transport and Patient requires rapid transport and

continued efforts at IV accesscontinued efforts at IV access Drug must be reconstituted prior to Drug must be reconstituted prior to

administrationadministration

AlbuterolAlbuterol

Ventolin, ProventilVentolin, Proventil Bronchodilator with onset 5 – 15 minutes Bronchodilator with onset 5 – 15 minutes

after inhalationafter inhalation Used in asthma, to reverse bronchospasm Used in asthma, to reverse bronchospasm

in COPD, and bronchospasm & laryngeal in COPD, and bronchospasm & laryngeal edema of an allergic reactionedema of an allergic reaction

All patients inhale 2.5 mg via nebulizerAll patients inhale 2.5 mg via nebulizer

Albuterol cont’dAlbuterol cont’d

May cause tachycardia & restlessnessMay cause tachycardia & restlessness Has greater influence in the lungs than Has greater influence in the lungs than

on the hearton the heart Less effective if patient taking beta Less effective if patient taking beta

blockers at home (usually for blockers at home (usually for hypertension; meds end in “alol”)hypertension; meds end in “alol”) Beta blockers block bronchodilation Beta blockers block bronchodilation

responseresponse Offer aerosol mask if patient unable to Offer aerosol mask if patient unable to

keep mouthpiece sealed between lipskeep mouthpiece sealed between lips

Albuterol Kit and MasksAlbuterol Kit and Masks

Watch for Watch for signs of signs of exhaustionexhaustion

May need to May need to be baggedbe bagged

2.5 mg / 3 ml

Connectedto O2

source

Available inadult andpediatric sizes

Epinephrine via NebulizerEpinephrine via Nebulizer

In presence of croup/epiglottitsIn presence of croup/epiglottits If patient not responding to 2 doses of If patient not responding to 2 doses of

Albuterol, provide alternate treatmentAlbuterol, provide alternate treatment• Epinephrine 1:1000 1 ml mixed with Epinephrine 1:1000 1 ml mixed with

2 ml normal saline2 ml normal saline• Mix in nebulizerMix in nebulizer• Connect to oxygen to create a mistConnect to oxygen to create a mist• Assist patient while inhaling the mistAssist patient while inhaling the mist

Nebulized Epinephrine for moderate to Nebulized Epinephrine for moderate to severe casessevere cases

Epinephrine 1:1000Epinephrine 1:1000

A drug that mimics the sympathetic nervous systemA drug that mimics the sympathetic nervous system Stimulation on the vessels trigger Stimulation on the vessels trigger

vasoconstrictionvasoconstriction• Will raise the blood pressureWill raise the blood pressure

Stimulation in the lungs triggers bronchodilationStimulation in the lungs triggers bronchodilation• Will improve air exchangeWill improve air exchange

Useful in asthma, COPD, allergic reactions with Useful in asthma, COPD, allergic reactions with airway involvement, and anaphylaxisairway involvement, and anaphylaxis

Epinephrine 1:1000 cont’dEpinephrine 1:1000 cont’d

Use with caution in the elderly and Use with caution in the elderly and those with heart diseasethose with heart disease Can strain the heart by increasing the Can strain the heart by increasing the

workload of the heart (rate and force of workload of the heart (rate and force of contractions)contractions)

Adult dosing allergic reaction with Adult dosing allergic reaction with airway involvement – 0.3 mg SQairway involvement – 0.3 mg SQ

Adult dosing anaphylaxis – 0.5 mg IMAdult dosing anaphylaxis – 0.5 mg IM Faster absorption in poor perfusionFaster absorption in poor perfusion

Epinephrine 1:1000 cont’dEpinephrine 1:1000 cont’d

Pediatric dosing up to 15 years of agePediatric dosing up to 15 years of age Allergic reaction with airway involvementAllergic reaction with airway involvement

• Epi 1:1000 - 0.01 mg/kg SQEpi 1:1000 - 0.01 mg/kg SQ• Max single dose 0.3 ml (0.3 mg)Max single dose 0.3 ml (0.3 mg)• May repeat every 15 minutesMay repeat every 15 minutes

AnaphylaxisAnaphylaxis• Epi 1:1000 – 0.01 mg/kg IMEpi 1:1000 – 0.01 mg/kg IM• Max single dose 0.3 ml (0.3 mg)Max single dose 0.3 ml (0.3 mg)• IM faster absorption in poor perfusion stateIM faster absorption in poor perfusion state• May repeat every 15 minutesMay repeat every 15 minutes

Epinephrine 1:1000 cont’dEpinephrine 1:1000 cont’d

May cause:May cause: TachyarrhythmiasTachyarrhythmias Palpitations Palpitations RestlessnessRestlessness Anxiety Anxiety HeadacheHeadache

May increase oxygen demand in the heartMay increase oxygen demand in the heart Use cautiously in elderly and those with heart Use cautiously in elderly and those with heart

diseasedisease

Benadryl - DiphenhydramineBenadryl - Diphenhydramine

Antihistamine to block the release of Antihistamine to block the release of histamine in allergic reactionshistamine in allergic reactions

Max effect in 1 – 3 hoursMax effect in 1 – 3 hours Duration of effect 6 -12 hoursDuration of effect 6 -12 hours

Medication must be continued over several Medication must be continued over several days or symptoms will rebound days or symptoms will rebound

Useful in allergic reactions including Useful in allergic reactions including anaphylaxisanaphylaxis

Benadryl cont’dBenadryl cont’d Avoid use in severe, uncontrolled asthma Avoid use in severe, uncontrolled asthma

and COPDand COPD Adult dosingAdult dosing

Stable allergic reaction – 25 mg slow IVP or IMStable allergic reaction – 25 mg slow IVP or IM Allergic reaction with airway involvement & Allergic reaction with airway involvement &

anaphylaxis – 50 mg slow IVP or IManaphylaxis – 50 mg slow IVP or IM Pediatric dosing – 1 mg/kg IVPPediatric dosing – 1 mg/kg IVP

Stable allergic reaction – max dose 25 mgStable allergic reaction – max dose 25 mg Allergic reaction with airway involvement or Allergic reaction with airway involvement or

anaphylaxis – max dose 50 mganaphylaxis – max dose 50 mg

Benadryl cont’dBenadryl cont’d

May cause drowsiness, headache, May cause drowsiness, headache, confusion, wheezing, palpitations, confusion, wheezing, palpitations, hypotension, nausea, vomiting, drying of hypotension, nausea, vomiting, drying of secretionssecretions

Elderly particularly sensitive to effects of Elderly particularly sensitive to effects of BenadrylBenadryl Watch for hypotension and drowsinessWatch for hypotension and drowsiness

Lasix (furosemide)Lasix (furosemide) Diuretic that stops reabsorption of Diuretic that stops reabsorption of

sodium and chloride in the kidneyssodium and chloride in the kidneys Triggers dilation of the venous systemTriggers dilation of the venous system

Could drop blood pressureCould drop blood pressure Decreases pre-load Decreases pre-load

Amount of blood returning to the heartAmount of blood returning to the heart Onset of venodilation immediateOnset of venodilation immediate Onset of diuretic effect within 15 – 20 Onset of diuretic effect within 15 – 20

minutesminutes

Lasix (furosemide) cont’dLasix (furosemide) cont’d

Useful in CHF and pulmonary edemaUseful in CHF and pulmonary edema Venodilation useful in hypertensive Venodilation useful in hypertensive

crisiscrisis Slight risk in persons allergic to sulfa Slight risk in persons allergic to sulfa

drugs (typically antibiotics)drugs (typically antibiotics) Dosing is 40 mg IVP/IODosing is 40 mg IVP/IO

If patient is on Lasix, they are If patient is on Lasix, they are sensitized to itsensitized to it

Use the larger dose of 80 mg IVP/IOUse the larger dose of 80 mg IVP/IO

Lasix (furosemide) cont’dLasix (furosemide) cont’d

May cause headache, dizziness, May cause headache, dizziness, hypovolemia, nauseahypovolemia, nausea

Patient may experience temporary hearing Patient may experience temporary hearing loss and ringing in the ears with repeated loss and ringing in the ears with repeated doses given doses given rapidrapid IVP/IO over a period of IVP/IO over a period of timetime

MorphineMorphine Narcotic analgesic (opioid)Narcotic analgesic (opioid)

Reduces anxietyReduces anxiety Creates a euphoric feelingCreates a euphoric feeling Depresses the central nervous system (CNS)Depresses the central nervous system (CNS)

• Reduces pain sensationReduces pain sensation Dilates venous blood vesselsDilates venous blood vessels

• Decreases blood return to the heart (pre-load)Decreases blood return to the heart (pre-load) Useful in ACS, pulmonary edema, painUseful in ACS, pulmonary edema, pain Potentiates versed during conscious sedationPotentiates versed during conscious sedation

Helps versed to be more effectiveHelps versed to be more effective

Morphine cont’dMorphine cont’d DosingDosing

2 mg given slow IVP (over 2 minutes)2 mg given slow IVP (over 2 minutes) May repeat every 2-3 minutesMay repeat every 2-3 minutes Maximum total dose is 10 mgMaximum total dose is 10 mg

Side effectsSide effects HypotensionHypotension Respiratory depressionRespiratory depression BradycardiaBradycardia Altered level of consciousnessAltered level of consciousness

Morphine cont’dMorphine cont’d Opioids cause pupils to constrictOpioids cause pupils to constrict Use cautiously when other depressant Use cautiously when other depressant

drugs have been takendrugs have been taken Includes alcoholIncludes alcohol

Reversal agent is NarcanReversal agent is Narcan Adult dosing 2 mg IVPAdult dosing 2 mg IVP

• May repeat every 5 minutes; max total 10 mgMay repeat every 5 minutes; max total 10 mg Pediatric dosing < 20kg – 0.1 mg/kg Pediatric dosing < 20kg – 0.1 mg/kg

IVP/IO/IMIVP/IO/IM• Max total dose is 2mg Max total dose is 2mg • > 20kg – 2 mg IVP/IO/IM> 20kg – 2 mg IVP/IO/IM

NarcanNarcan Narcotic antagonist with an onset within Narcotic antagonist with an onset within

2 minutes2 minutes May cause withdrawal symptoms including May cause withdrawal symptoms including

seizuresseizures Adult dose – 2 mg IN/IVP/IOAdult dose – 2 mg IN/IVP/IO

Repeated every 5 minutes as needed up to 10 mgRepeated every 5 minutes as needed up to 10 mg

Pediatric dose up to 15 years weight basedPediatric dose up to 15 years weight based <<20 kg (44#) – 0.1 mg/kg IVP/IO/IM20 kg (44#) – 0.1 mg/kg IVP/IO/IM >20 kg (44# - typically a 4-6 year old) – >20 kg (44# - typically a 4-6 year old) –

2 mg IVP/IO/IM 2 mg IVP/IO/IM

Narcan cont’dNarcan cont’d

Side effects are rare. Watch for Side effects are rare. Watch for hypotension, nausea, vomiting, blurred hypotension, nausea, vomiting, blurred vision, opiate withdrawal (including vision, opiate withdrawal (including seizures)seizures)

Goal is to reverse severe respiratory Goal is to reverse severe respiratory depression; depression; NOTNOT to have an awake & to have an awake & talking patienttalking patient

Duration of Narcan may be shorter than Duration of Narcan may be shorter than drug it is trying to counteractdrug it is trying to counteract Watch for return of symptomsWatch for return of symptoms

Alternate Medication Delivery - Alternate Medication Delivery - MAD MAD

MMucosal ucosal aatomization tomization ddeviceevice Tool to deliver medications via nasal routeTool to deliver medications via nasal route

Medication atomized into tiny particlesMedication atomized into tiny particles Nasal mucosa highly vascularNasal mucosa highly vascular

• Immediate absorption into bloodstreamImmediate absorption into bloodstream

• Onset of action within 3-5 minutesOnset of action within 3-5 minutes

• Peak onset 15-20 minutesPeak onset 15-20 minutes

Using Nasal Route - MADUsing Nasal Route - MAD Unable to establish IV accessUnable to establish IV access Medication administration indicatedMedication administration indicated Nasal mucosa intact and Nasal mucosa intact and

clear of blood and mucusclear of blood and mucus

MADMAD

Luer tip can be connected to variety of sizes Luer tip can be connected to variety of sizes of syringeof syringe

White wedge fits firmly into nostrilWhite wedge fits firmly into nostril Fine mist spray covers a large surface areaFine mist spray covers a large surface area Medication adheres to nasal mucosa Medication adheres to nasal mucosa

versus running down the throat versus running down the throat Each nostril can tolerate up to 1 ml volumeEach nostril can tolerate up to 1 ml volume

Narcan packaged 2mg/2ml – will need to deliver Narcan packaged 2mg/2ml – will need to deliver 1 ml in each nostril1 ml in each nostril

Attaching MAD Tip to SyringeAttaching MAD Tip to Syringe

Nasal cavity suctioned as needed to clear blood or secretions• Clear nasal passages enhance absorption

of medication Medication delivered in divided dosesMedication delivered in divided doses

• Maximum of 1 ml per naresMaximum of 1 ml per nares

Inserting MAD NasalInserting MAD Nasal

Patient’s head controlled with Patient’s head controlled with one handone hand Need to prevent movementNeed to prevent movement

• MAD gently but firmly placed MAD gently but firmly placed into one nostrilinto one nostril• Aimed upward and toward Aimed upward and toward

ear on same sideear on same side

Syringe briskly compressed Syringe briskly compressed to deliver the drug as an to deliver the drug as an atomized mist into naresatomized mist into nares

Dispensing MistDispensing Mist

Must briskly compress Must briskly compress syringe to convert liquid syringe to convert liquid drug to a fine atomized drug to a fine atomized mistmist Mist results in broader Mist results in broader

mucosal coverage; mucosal coverage; better chance of better chance of absorption into the absorption into the blood stream than blood stream than drops that can run drops that can run straight back into the straight back into the throat.throat.

MADMAD

Region X have implemented the MAD Region X have implemented the MAD beginning with Narcanbeginning with Narcan

“ “IN” documented for route of IN” documented for route of administrationadministration

Will have the potential in the future to Will have the potential in the future to add further medication using the MAD add further medication using the MAD

Cricothyrotomy, QuickTrachCricothyrotomy, QuickTrach

IndicationsIndications Assisted ventilations required and all other Assisted ventilations required and all other

means have failed to secure an airwaymeans have failed to secure an airway ContraindicationsContraindications

Transected tracheaTransected trachea Less invasive maneuver will be effectiveLess invasive maneuver will be effective

Note: In ED, staff will need to assist the Note: In ED, staff will need to assist the MD with this device – do you know how?MD with this device – do you know how?

EquipmentEquipment

BVMBVM QuickTrach kitQuickTrach kit

>77 pounds use 4 mm kit>77 pounds use 4 mm kit 22 – 77 pounds use 2 mm kit22 – 77 pounds use 2 mm kit < 22 pounds use needle cricothyrotomy< 22 pounds use needle cricothyrotomy

Skin prep materialSkin prep material

Where is your airway kit kept in the Where is your airway kit kept in the EDED??

QuickTrach Kit QuickTrach Kit ContentsContents

Needle with syringeNeedle with syringe Cannula with wings Cannula with wings

for strap attachmentfor strap attachment Extension tubingExtension tubing Velcro strapVelcro strap

QuickTrach cont’dQuickTrach cont’d Procedure (RN to assist MD)Procedure (RN to assist MD)

Assemble equipmentAssemble equipment Patient supine, neck hyperextended if no traumaPatient supine, neck hyperextended if no trauma Locate cricothyroid membrane and cleanse siteLocate cricothyroid membrane and cleanse site

• Soft spot palpated just below Adam’s appleSoft spot palpated just below Adam’s apple• Or, start at notch, run fingers up toward headOr, start at notch, run fingers up toward head

First ridge of bone palpated is cricoid First ridge of bone palpated is cricoid cartilagecartilage

Membrane is just above this bony cartilageMembrane is just above this bony cartilage

Procedure cont’dProcedure cont’d Anchor and stretch skin slightlyAnchor and stretch skin slightly Puncture cricothyroid membrane at 90Puncture cricothyroid membrane at 9000 angle angle Aspirate syringe as needle enters trachea to confirm Aspirate syringe as needle enters trachea to confirm

placementplacement• Ability to freely aspirate airAbility to freely aspirate air

Change angle of needle to 60Change angle of needle to 6000 towards feet towards feet Advance device until stopper is flush with skinAdvance device until stopper is flush with skin Remove stopperRemove stopper

• Stopper will be snug; avoid motion of needleStopper will be snug; avoid motion of needle Slide plastic cannula forward until snug against skin as Slide plastic cannula forward until snug against skin as

you remove needle and syringeyou remove needle and syringe• Advance cannula as you remove needle like starting Advance cannula as you remove needle like starting

an IVan IV

Procedure cont’dProcedure cont’d Hold cannula snugglyHold cannula snuggly

• Patient may reflexively cough and could Patient may reflexively cough and could dislodge cannuladislodge cannula

Attach flexible connecting tube to cannula Attach flexible connecting tube to cannula proximal endproximal end

Begin to bag/ventilate the patient immediatelyBegin to bag/ventilate the patient immediately• Once every 6-8 seconds for all patientsOnce every 6-8 seconds for all patients

Confirm placementConfirm placement• Auscultation lung soundsAuscultation lung sounds• Adequate chest riseAdequate chest rise

Finish securing cannula with neck strapFinish securing cannula with neck strap

Case Study #1Case Study #1

Your patient called 911 after dropping her tea Your patient called 911 after dropping her tea cup and being unable to move her right sidecup and being unable to move her right side

Conscious, cooperative, speech slurredConscious, cooperative, speech slurred VS: 175/110; P – 98; R – 18; pupils cataractVS: 175/110; P – 98; R – 18; pupils cataract Initial care started (IV – OInitial care started (IV – O22 – monitor) – monitor) What is your impression?What is your impression? What specific assessment should be done?What specific assessment should be done?

Case Study #1 cont’dCase Study #1 cont’d

ImpressionImpression Acute strokeAcute stroke

Additional assessmentAdditional assessment Cincinnati Stroke ScaleCincinnati Stroke Scale

• Facial droopFacial droop• Arm driftArm drift• SpeechSpeech

Transport decisionTransport decision Is CT scan available at receiving hospital?Is CT scan available at receiving hospital?

Case Study #2Case Study #2 EMS is at a local school for a patient with asthmaEMS is at a local school for a patient with asthma Assessment taken walking towards childAssessment taken walking towards child

Sitting uprightSitting upright In obvious distressIn obvious distress

• Use of accessory muscles – neck, intercostalUse of accessory muscles – neck, intercostal• Increased respiratory rateIncreased respiratory rate• Panic on their facePanic on their face

ImpressionImpression• Severe acute asthma attackSevere acute asthma attack

Is assessment done after vital signs?Is assessment done after vital signs?

Case Study #2 cont’dCase Study #2 cont’d

Assessment performedAssessment performed Observation / visual inspectionObservation / visual inspection Initial ABC’sInitial ABC’s

• To determine presence of life threatsTo determine presence of life threats Breath sounds auscultatedBreath sounds auscultated

• Bilateral wheezing heard predominately on Bilateral wheezing heard predominately on exhalationexhalation

Obtain vital signsObtain vital signs

• 98/62; P – 110; R – 28 and labored; SpO98/62; P – 110; R – 28 and labored; SpO2 2 94%94%

Case Study #2 cont’dCase Study #2 cont’d

Interventions requiredInterventions required IV – OIV – O22 – monitor - medication – monitor - medication

QuestionQuestion Do you need an IV established prior to Do you need an IV established prior to

administration of medication?administration of medication?• No, albuterol nebulizer should be started as No, albuterol nebulizer should be started as

soon as possiblesoon as possible• Give verbal prompts to slow breathing down, to Give verbal prompts to slow breathing down, to

take deeper breaths, and to eventually take and take deeper breaths, and to eventually take and hold a deep breathhold a deep breath

Case Study #3Case Study #3

You are caring for a traumatically injured You are caring for a traumatically injured patientpatient

When asking them to open their eyes, you When asking them to open their eyes, you yelled their name and their eye opened briefly yelled their name and their eye opened briefly and then closed againand then closed again

They are using swear words during care They are using swear words during care providedprovided

They are pulling off equipment and grabbing They are pulling off equipment and grabbing at your hands while you provide careat your hands while you provide care

What is their GCS?What is their GCS?

Case Study #3 cont’dCase Study #3 cont’d

Eye openingEye opening To verbal – 3 pointsTo verbal – 3 points

Verbal responseVerbal response Inappropriate words – 3 pointsInappropriate words – 3 points

Motor responseMotor response Purposeful movement – 5 pointsPurposeful movement – 5 points

Total GCS – 11 pointsTotal GCS – 11 points Indicates moderate head injuryIndicates moderate head injury

Case Study #4Case Study #4

You are caring for a patient complaining You are caring for a patient complaining of dyspneaof dyspnea

Your patient is 62 years-oldYour patient is 62 years-old They are sitting in the tripod positionThey are sitting in the tripod position They are using accessory muscles and They are using accessory muscles and

have an increased respiratory ratehave an increased respiratory rate With your stethoscope, you auscultate With your stethoscope, you auscultate

crackling sounds heard in the bases crackling sounds heard in the bases during exhalationduring exhalation

Case Study #4 cont’dCase Study #4 cont’d What are these breath sounds?What are these breath sounds?

CracklesCrackles What do these breath sounds indicate?What do these breath sounds indicate?

Fluid in the smaller airwaysFluid in the smaller airways• CHF, pulmonary edema, pneumoniaCHF, pulmonary edema, pneumonia

What medications may be indicated in the What medications may be indicated in the field (per SOP) for CHF?field (per SOP) for CHF? Nitroglycerin – venodilatorNitroglycerin – venodilator Lasix – venodilator and diureticLasix – venodilator and diuretic Morphine – venodilator, reduce anxietyMorphine – venodilator, reduce anxiety And of course, oxygenAnd of course, oxygen

Intervention to add is CPAPIntervention to add is CPAP

Case Study #5Case Study #5

You received a 7 year-old patient from a You received a 7 year-old patient from a local school with an asthma attacklocal school with an asthma attack

Your impression is an acute asthma attackYour impression is an acute asthma attack You begin supplemental oxygen and begin You begin supplemental oxygen and begin

to prepare to provide interventionsto prepare to provide interventions

Case Study #5 cont’dCase Study #5 cont’d If this is an asthma attack, what signs and If this is an asthma attack, what signs and

symptoms do you expect?symptoms do you expect? Sitting up leaning forwardSitting up leaning forward Dyspnea with shortness of breathDyspnea with shortness of breath Increased respiratory rateIncreased respiratory rate Use of accessory musclesUse of accessory muscles Dry mucous membranesDry mucous membranes Possibly audible wheezing Possibly audible wheezing Bilateral wheezing heard first on exhalationBilateral wheezing heard first on exhalation Dry, nonproductive coughDry, nonproductive cough

Case Study #5 cont’dCase Study #5 cont’d

If you cannot hear any breath sounds, If you cannot hear any breath sounds, what does this mean?what does this mean? The airway is so constricted that no air is The airway is so constricted that no air is

moving in or out – ominousmoving in or out – ominous What does wheezing sound like?What does wheezing sound like?

Whistling, musical sound that can be heard Whistling, musical sound that can be heard on inhalation and exhalationon inhalation and exhalation• The louder the breath sounds the more The louder the breath sounds the more

air that is exchangingair that is exchanging

Case Study #5 cont’dCase Study #5 cont’d

What medication is indicated?What medication is indicated? Albuterol 2.5 mg (in 3 ml) nebulizerAlbuterol 2.5 mg (in 3 ml) nebulizer

How can you help maximize the effects of the How can you help maximize the effects of the treatment?treatment? Calmly, quietly talk the patient through breathingCalmly, quietly talk the patient through breathing Get the patient to slow down the breathingGet the patient to slow down the breathing Get the patient to take some deeper breathsGet the patient to take some deeper breaths Get the patient to inhale and hold their breath Get the patient to inhale and hold their breath

periodically to get the drug into the lungsperiodically to get the drug into the lungs

Case Study #6Case Study #6

You have an unresponsive male in his You have an unresponsive male in his twentiestwenties

The patient responds to painful stimuliThe patient responds to painful stimuli The respirations are 6 per minute and The respirations are 6 per minute and

shallowshallow Pupils are constrictedPupils are constricted What is your impression?What is your impression? What interventions were necessary in What interventions were necessary in

the field?the field?

Case Study #6Case Study #6 ImpressionImpression

Narcotic overdoseNarcotic overdose InterventionsInterventions

Immediately support ventilationsImmediately support ventilations

• Bag at a rate of once every 5-6 secondsBag at a rate of once every 5-6 seconds Protect the airway from aspirationProtect the airway from aspiration Administer Narcan 2 mg (via MAD if no IV)Administer Narcan 2 mg (via MAD if no IV)

• Administer a maximum of 1 ml per nares if Administer a maximum of 1 ml per nares if using MADusing MAD

Case Study #7Case Study #7

A patient is unable to be ventilated via A patient is unable to be ventilated via BVMBVM

What options are available?What options are available? Reposition the airwayReposition the airway

• Consider c-spine precautions if indicatedConsider c-spine precautions if indicated Attempt intubationAttempt intubation QuickTrach if unable to intubateQuickTrach if unable to intubate Needle cricothyrotomy if unable to identify Needle cricothyrotomy if unable to identify

landmarkslandmarks

Case Study #7Case Study #7

Landmarks for QuicktrachLandmarks for Quicktrach Soft space just inferior/below thyroid cartilage Soft space just inferior/below thyroid cartilage

(Adam’s apple)(Adam’s apple) OrOr Start in notch and move finger upwardStart in notch and move finger upward

• Feel first bony prominence – cricoid Feel first bony prominence – cricoid cartilagecartilage

• Palpate for soft space above the cricoid Palpate for soft space above the cricoid cartilagecartilage

BibliographyBibliography

Bledsoe, B., Porter, R., Cherry, R. Paramedic Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall. Care Principles and Practices. Prentice Hall. 2009.2009.

Campbell, J. BTLS 5Campbell, J. BTLS 5thth Edition. Brady. 2004. Edition. Brady. 2004. Region X SOP, March 2007; amended January Region X SOP, March 2007; amended January

1, 2008.1, 2008. videolaryngoscopy.com/…/AdultCobalt-videolaryngoscopy.com/…/AdultCobalt-

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