Philosophy of Five - Login - · PDF filePhilosophy of Five Paul R ... Objective A change in your practice Protocols and Medical Control The importance of history taking Formulating

Philosophy of FivePhilosophy of Five

Paul R. Hinchey, MD MBAPaul R. Hinchey, MD MBA

Medical DirectorMedical Director

AustinAustin--Travis County EMSTravis County EMS

ObjectiveObjective

�� A change in your practiceA change in your practice

�� Protocols and Medical ControlProtocols and Medical Control

�� The importance of history takingThe importance of history taking

�� Formulating a differential diagnosisFormulating a differential diagnosis

�� How to stay the courseHow to stay the course

�� Performance improvement and errorsPerformance improvement and errors

AssessmentAssessment

A change in your practice A change in your practice

�� You are a You are a practitionerpractitioner of outof out--ofof--hospital hospital

medicinemedicine

�� Greatest asset is knowledgeGreatest asset is knowledge

�� Complex differential diagnosisComplex differential diagnosis

�� Advanced assessmentAdvanced assessment

�� Advanced decision makingAdvanced decision making

�� With great power comes great responsibilityWith great power comes great responsibility

Great ResponsibilityGreat Responsibility

�� IVs, airways and drugs are IVs, airways and drugs are

tools in a toolboxtools in a toolbox

�� They do NOT define who They do NOT define who

you are!you are!

�� Skills are the purview of the Skills are the purview of the

technician; thoughtful technician; thoughtful

application of the science is application of the science is

the duty of the practitioner.the duty of the practitioner.

Be a practitioner!Be a practitioner!

�� Gather informationGather information

�� Consider possible conditionsConsider possible conditions

�� Confirm or refute possibilitiesConfirm or refute possibilities

�� Treat those conditions that remainTreat those conditions that remain

�� Patient centeredPatient centered

�� Evidence basedEvidence based

�� Outcome orientedOutcome oriented

Gathering Information Gathering Information

&&

The Differential DiagnosisThe Differential Diagnosis

Differential DiagnosisDifferential Diagnosis

�� Mental process of considering different Mental process of considering different diagnoses given presenting condition.diagnoses given presenting condition.

�� Begins broadly based on chief complaint and is Begins broadly based on chief complaint and is narrowed through questioning, exam findings, narrowed through questioning, exam findings, test results and response to treatment.test results and response to treatment.

�� Prevents Prevents ““premature closurepremature closure”” -- the act of the act of establishing a diagnosis despite available establishing a diagnosis despite available information to the contrary and the failure to information to the contrary and the failure to pursue additional diagnostic possibilities pursue additional diagnostic possibilities

Make a habit of developing a Make a habit of developing a

differential of at least 3differential of at least 3--5 possible 5 possible

diseases or conditions for each diseases or conditions for each

patient you see patient you see

History of Present IllnessHistory of Present Illness

�� 95% of your differential formed by chief 95% of your differential formed by chief complaint and HPIcomplaint and HPI

�� Past history medications and social history help Past history medications and social history help develop contributors and identify the history not develop contributors and identify the history not provided by the patientprovided by the patient

�� In modern era physical exam is usually minor In modern era physical exam is usually minor contributioncontribution

�� Laboratory and imaging studies are confirmatoryLaboratory and imaging studies are confirmatory


�� CCCC

�� HPIHPI

�� AMPLEAMPLE

�� Allergies, meds, past medical, surgical, family and Allergies, meds, past medical, surgical, family and social history, last meal, events leading up to the social history, last meal, events leading up to the incidentincident

�� Review of SystemsReview of Systems

�� Physical ExamPhysical Exam

�� Diagnostic studiesDiagnostic studies

Remember the patient doesnRemember the patient doesn’’t know t know

what information to providewhat information to provide…….the .the

burden is on you to elicit the burden is on you to elicit the

information needed to form a information needed to form a

differential diagnosisdifferential diagnosis

Chief Complaint and HPIChief Complaint and HPI

�� Whenever possible is in patients own wordsWhenever possible is in patients own words

�� Sets foundation to develop differentialSets foundation to develop differential

�� History of present illness builds the frameworkHistory of present illness builds the framework

�� Systematic approach speeds process and eliminates Systematic approach speeds process and eliminates

errors of omissionerrors of omission

�� Can be boiled down into 10 cardinal questionsCan be boiled down into 10 cardinal questions

Cardinal Questions of HPICardinal Questions of HPI

�� Location Location –– where is itwhere is it

�� OOnset nset –– sudden or gradual, intermittentsudden or gradual, intermittent

�� PPrecipitating event(s) recipitating event(s) –– what were you doing what were you doing

�� QQuality uality –– stabbing, cramping, tearing, aching, burningstabbing, cramping, tearing, aching, burning

�� RRadiation adiation –– does it go anywhere does it go anywhere

�� SSeverity everity –– 11--1010

�� TTime/Durationime/Duration-- when did it start or how long does it lastwhen did it start or how long does it last

�� Aggravating/Alleviating Aggravating/Alleviating –– anything make better/worseanything make better/worse

�� Associated symptoms Associated symptoms –– what symptoms came with itwhat symptoms came with it

�� Prior history of same/similarPrior history of same/similar

DifferentialDifferential

�� VascularVascular

�� Infectious / inflammatoryInfectious / inflammatory

�� Trauma / ToxinsTrauma / Toxins

�� AutoimmuneAutoimmune

�� MetabolicMetabolic

�� IdiopathicIdiopathic

�� NeoplasticNeoplastic

�� CongenitalCongenital

How this worksHow this works……

85 y/o complaining of chest pain.85 y/o complaining of chest pain.


�� Location Location –– right chestright chest

�� Onset Onset –– suddensudden

�� DurationDuration-- 15 minutes prior to calling15 minutes prior to calling

�� Precipitating event(s) Precipitating event(s) –– Just stood from chairJust stood from chair

�� Severity Severity ––1010

�� Quality Quality –– sharp/stabbingsharp/stabbing

�� Radiation Radiation –– nonenone

�� Aggravating Aggravating –– moving taking a deep breathmoving taking a deep breath

�� Alleviating Alleviating –– improves somewhat with sitting stillimproves somewhat with sitting still

�� Associated symptoms Associated symptoms –– racing heart, profound SOB, swollen legracing heart, profound SOB, swollen leg

�� Prior history of same/similarPrior history of same/similar-- nonenone










What is the diagnosis?What is the diagnosis?

Same CC different 85 y/o oldSame CC different 85 y/o old……

�� Location Location –– left chestleft chest

�� Onset Onset –– gradualgradual

�� DurationDuration-- 2 days2 days

�� Precipitating event(s) Precipitating event(s) –– uriuri

�� Severity Severity –– 88

�� Quality Quality –– sharp/achingsharp/aching

�� Radiation Radiation –– nonenone

�� Aggravating Aggravating –– deep inspirationdeep inspiration

�� Alleviating Alleviating –– nonenone

�� Associated symptoms Associated symptoms –– cough productive of brown sputum, cough productive of brown sputum, shortness of breath, fevers to 102.5shortness of breath, fevers to 102.5











What is the diagnosis?What is the diagnosis?

Patient TransferPatient Transfer

�� Common time for errors that affect patientsCommon time for errors that affect patients

�� Almost all transfer errors relate to Almost all transfer errors relate to

communication communication

�� Standardization reduces these errors:Standardization reduces these errors:

�� (sender) reduces chance of overlooking info(sender) reduces chance of overlooking info

�� (receiver) allows (receiver) allows ““filingfiling”” of info as presentedof info as presented

Transfer of InformationTransfer of Information

�� Age, pertinent past med hx and current chief Age, pertinent past med hx and current chief

complaintcomplaint

�� HPI info (learned from 10 cardinal questions)HPI info (learned from 10 cardinal questions)

�� Pertinent exam findings vitalsPertinent exam findings vitals

�� Interventions and responseInterventions and response

�� It doesnIt doesn’’t have to be perfectt have to be perfect……if they want more if they want more

info they will ask!info they will ask!

ExampleExample

This is Ms Smith who is a 75 y/o with a history of high This is Ms Smith who is a 75 y/o with a history of high blood pressure, and COPD who called today for chest blood pressure, and COPD who called today for chest pain with shortness of breath. Developed gradually pain with shortness of breath. Developed gradually over the last 2 days after an upper respiratory infection. over the last 2 days after an upper respiratory infection. She has sharp 8:10 isolated to her left chest which is She has sharp 8:10 isolated to her left chest which is made worse with deep breaths but has no other made worse with deep breaths but has no other modifying factors. She has also had a fever and cough modifying factors. She has also had a fever and cough productive of some brown sputum.productive of some brown sputum.

She has increased work of breathing and course crackles She has increased work of breathing and course crackles on the left base. Temp 103, P100, R 26, BP 140/70, on the left base. Temp 103, P100, R 26, BP 140/70, initial O2 sat was 89% which has come up to 93% on initial O2 sat was 89% which has come up to 93% on NRFM. She has an IV in her left AC.NRFM. She has an IV in her left AC.

FR Transfer of InfoFR Transfer of Info

�� FR will be educated on this formatFR will be educated on this format

�� There is a learning curveThere is a learning curve

�� Listen to your FR Listen to your FR

�� BE PATIENTBE PATIENT

�� Look for teaching momentsLook for teaching moments

�� Be professionalBe professional

Editorial CommentEditorial Comment

�� Have you ever presented a patient to an ED doc Have you ever presented a patient to an ED doc

and they didnand they didn’’t listen to you?t listen to you?

�� Have you ever had an ED doc belittle your Have you ever had an ED doc belittle your

contribution to patient care?contribution to patient care?

�� Have you ever had an ED doc treat you like you Have you ever had an ED doc treat you like you

were an idiot?were an idiot?

How did that make you feel?How did that make you feel?

Why……

would you do it to someone else?

Questions?Questions?

Medical Direction Medical Direction

and and

EMS SystemsEMS Systems

Medical DirectorMedical Director

�� EducationEducation

�� Any limitations on what you learn is self imposedAny limitations on what you learn is self imposed

�� You are responsible for what is taughtYou are responsible for what is taught

�� Evidence based protocolsEvidence based protocols

�� We follow the science We follow the science –– or or ––

�� We help to define itWe help to define it

�� Performance ImprovementPerformance Improvement

�� How we learn as a systemHow we learn as a system

�� Advocacy for providers and the professionAdvocacy for providers and the profession

PrePre--Hospital PracticeHospital Practice

�� You are a practitioner of prehospital medicineYou are a practitioner of prehospital medicine

�� Protocols are there to guide the decision making Protocols are there to guide the decision making

process and treatmentprocess and treatment

�� No protocol will cover every situationNo protocol will cover every situation……you you

must be able to and are expected to thinkmust be able to and are expected to think

�� Medical Control is there to help you in decision Medical Control is there to help you in decision

making and when you have to deviate from making and when you have to deviate from

protocolprotocol

These are YOUR patientsThese are YOUR patients

�� You are responsible for themYou are responsible for them

�� Utilize whatever resources you needUtilize whatever resources you need

�� SupervisorsSupervisors

�� Medical ControlMedical Control

DonDon’’t carry the coffin alone!t carry the coffin alone!

How to stay the courseHow to stay the course

�� Keep up with learningKeep up with learning

�� ““Learning is like rowing Learning is like rowing

upstream: not to advance upstream: not to advance

is to drop back.is to drop back.”” ––

Chinese proverb Chinese proverb


How to stay the courseHow to stay the course

�� The BIG 3:The BIG 3:

�� Do what is in the best Do what is in the best

interest of the interest of the

patientpatient……..ALWAYS!..ALWAYS!

�� Do not lieDo not lie

�� Do not fudge Do not fudge

documentationdocumentation

�� Relationship is based on Relationship is based on

TRUSTTRUST

PIPI

�� Is NOT an inquisitionIs NOT an inquisition

�� Learn if/why a mistake was madeLearn if/why a mistake was made

�� What contributed to the mistakeWhat contributed to the mistake

�� Common goalsCommon goals

�� Improve the systemImprove the system

�� Assure we donAssure we don’’t make the same mistake againt make the same mistake again

�� Provide the best care possibleProvide the best care possible

�� Part of your obligation as a professionalPart of your obligation as a professional

ErrorsErrors

�� Errors are expectedErrors are expected

�� Cognitive errorsCognitive errors

�� Failure to take correct action due to knowledge Failure to take correct action due to knowledge

deficit or faulty decision makingdeficit or faulty decision making

�� Errors of omissionErrors of omission

�� Have knowledge but failed to properly executeHave knowledge but failed to properly execute

�� System design to minimize these errorsSystem design to minimize these errors

�� As long as there are human caregivers there will As long as there are human caregivers there will

be errorsbe errors

What if I make a mistake?What if I make a mistake?

�� Everyone will at some timeEveryone will at some time

�� Goal is to educate, train and improveGoal is to educate, train and improve

�� If you think you might have made a If you think you might have made a

mistakemistake……call someonecall someone

�� Protects youProtects you

�� Protects meProtects me

�� Protects the systemProtects the system

Inexcusable ErrorsInexcusable Errors

�� Actions not in the patients best interestActions not in the patients best interest

�� If there is ever a question as to what to doIf there is ever a question as to what to do……ask ask

yourself what you would want someone to do if it yourself what you would want someone to do if it

were your parent, child, spouse, etcwere your parent, child, spouse, etc……

�� The failure to learn from errors made by me, The failure to learn from errors made by me,

your colleagues or yourself.your colleagues or yourself.

Overview of an Overview of an

EMS SystemEMS System

What makes a What makes a

GREAT GREAT

EMS system?EMS system?

EMS Systems: What We DoEMS Systems: What We Do

�� 9090--95% of our responses are to non95% of our responses are to non--

emergenciesemergencies

�� Provide basics of human careProvide basics of human care

�� ComfortComfort

�� ReassuranceReassurance

�� TransportationTransportation

�� Duty is to serveDuty is to serve

EMS Systems: What Defines Us?EMS Systems: What Defines Us?

�� 55--10% of our responses are true life threats10% of our responses are true life threats

�� ProvideProvide

�� Life saving interventionLife saving intervention

�� Reduced mortality and morbidityReduced mortality and morbidity

�� Small but essential part of what we do Small but essential part of what we do

�� Defines us from public standpointDefines us from public standpoint

�� Core expectation from the publicCore expectation from the public

Life ThreatsLife Threats

�� Ability to manage these conditions is Ability to manage these conditions is

fundamental to any systemfundamental to any system

�� These are to a System what blocking and These are to a System what blocking and

tackling is to footballtackling is to football

�� If you can not do these wellIf you can not do these well……you can not be you can not be

greatgreat

Great PreGreat Pre--Hospital Health SystemsHospital Health Systems

�� There is no provider more important than There is no provider more important than

another in great EMS systemsanother in great EMS systems

�� They have differentThey have different

�� ResponsibilitiesResponsibilities

�� RolesRoles

�� TrainingTraining

�� They have a common goalThey have a common goal

Life ThreatsLife Threats

�� Life threats are the responsibility of EVERY Life threats are the responsibility of EVERY

provider in the systemprovider in the system

�� Life saving interventions are delivered by the Life saving interventions are delivered by the

first unit on scene regardless of the color of your first unit on scene regardless of the color of your

uniform, truck, patch, etc.uniform, truck, patch, etc.

�� Interventions for immediate life threats are all Interventions for immediate life threats are all

BASIC interventionsBASIC interventions

Philosophy of FivePhilosophy of Five

�� Time DependentTime Dependent

�� Acute MI (STEMI)Acute MI (STEMI)

�� Acute StrokeAcute Stroke

�� Trauma / Surgical EmergencyTrauma / Surgical Emergency

�� Intervention DependentIntervention Dependent

�� Cardiac ArrestCardiac Arrest

�� Respiratory DistressRespiratory Distress

Time DependentTime Dependent

�� These conditions can not be definitively treated These conditions can not be definitively treated

in the prein the pre--hospital environmenthospital environment

�� Requires specialized intervention only available Requires specialized intervention only available

in the hospitalin the hospital

�� Outcomes are linked to timely interventionOutcomes are linked to timely intervention

�� Goal is Goal is recognitionrecognition and and short scene intervalshort scene interval

Intervention DependentIntervention Dependent

�� Initial treatment can be delivered in prehospital Initial treatment can be delivered in prehospital

environmentenvironment

�� Outcomes linked to prehospital interventionsOutcomes linked to prehospital interventions

�� Goal is Goal is identificationidentification and and initiation of initiation of

treatmenttreatment

�� Scene intervals are NOT criticalScene intervals are NOT critical

Be PatientBe Patient

�� New educational initiativesNew educational initiatives

�� Patient centered and system oriented Patient centered and system oriented

�� This takes time to:This takes time to:

�� Change the cultureChange the culture

�� Move information across systemMove information across system

�� Be tolerant of your fellow providersBe tolerant of your fellow providers

�� Give and receive feedback Give and receive feedback


Cardiac ArrestCardiac Arrest

ObjectiveObjective

�� Describe the importance of:Describe the importance of:

�� Prehospital resuscitationPrehospital resuscitation

�� Continuous compressionContinuous compression

�� Controlled ventilatory rates Controlled ventilatory rates

�� Describe the value and limitations of advanced Describe the value and limitations of advanced

airway management adjunctsairway management adjuncts

�� List the critical components of cardiac arrest List the critical components of cardiac arrest

managementmanagement

Why do we worry about CAWhy do we worry about CA

�� Represents < 1% of our calls butRepresents < 1% of our calls but……

�� > 70% of CA arrests occur outside the hospital> 70% of CA arrests occur outside the hospital

�� Definitive management of cardiac arrest is in the Definitive management of cardiac arrest is in the

prehospital environment prehospital environment

““Stated succinctly, if ACLS care in Stated succinctly, if ACLS care in

the field cannot resuscitate the the field cannot resuscitate the

victim, ED care will not resuscitate victim, ED care will not resuscitate

the victim.the victim.””--

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation

and Emergency Cardiovascular Care (Part 7.2: Management of Cardiac Arrest)

YOUYOU

are the experts in cardiac arrest are the experts in cardiac arrest

resuscitation!resuscitation!

Priorities in OOHCA ChangedPriorities in OOHCA Changed

�� Emphasis on compressionEmphasis on compression

�� Limit interruptions from ANYTHINGLimit interruptions from ANYTHING

�� Goal is to maximize % of time in compressionsGoal is to maximize % of time in compressions

�� Single DSingle D--fib every two minutesfib every two minutes

�� Compress while chargingCompress while charging

�� Follow dFollow d--fib immediately by compressionsfib immediately by compressions

�� Decreased importance of ventilationsDecreased importance of ventilations

�� Fewer number of breaths Fewer number of breaths

�� Each delivered more slowlyEach delivered more slowly

So if you had to push So if you had to push

a car, would you a car, would you

push a few feet and push a few feet and

stopstop…….. only to .. only to

start again a few start again a few

minutes later?minutes later?

InertiaInertia……....

itit’’s not just for cars anymore!s not just for cars anymore!

Blood Inertia?

So if compressions are the MOST So if compressions are the MOST

important intervention for a important intervention for a

successful resuscitation what is our successful resuscitation what is our

airway management device of choice airway management device of choice

in a cardiac arrest?in a cardiac arrest?

…….more on this later.more on this later

Ventilation vs OxygenationVentilation vs Oxygenation

�� Oxygenation is delivery of oxygen to RBC and Oxygenation is delivery of oxygen to RBC and tissues tissues

�� Oxygenation determined by two things:Oxygenation determined by two things:

�� FiOFiO22 ((% inspired O% inspired O22))

�� Pressure of gas (CPAP or PEEP)Pressure of gas (CPAP or PEEP)

�� Ventilation is the elimination of COVentilation is the elimination of CO22

�� Ventilation is determined by two things:Ventilation is determined by two things:

�� Tidal volumeTidal volume

�� Ventilatory rateVentilatory rate

Why is this important?Why is this important?

�� Cells require oxygen to make energyCells require oxygen to make energy

�� Inability to oxygenate the tissue is quickly fatalInability to oxygenate the tissue is quickly fatal

�� Exchanging carbon dioxide is NOT!Exchanging carbon dioxide is NOT!

�� If forced to make the choice between If forced to make the choice between oxygenation and CO2 exchangeoxygenation and CO2 exchange

CHOOSE OXYGENATION!CHOOSE OXYGENATION!

So why does that matter?So why does that matter?

�� If oxygenation has nothing to do with If oxygenation has nothing to do with

ventilation why do we ventilate patients at rates ventilation why do we ventilate patients at rates

> 30 breaths per minute?> 30 breaths per minute?

�� Who caresWho cares……..if breathing 12 times a minute is ..if breathing 12 times a minute is

good 30 times a minute MUST be better right?good 30 times a minute MUST be better right?

High Ventilation Rates are BADHigh Ventilation Rates are BAD

�� Normal inspiration is negative pressureNormal inspiration is negative pressure

�� Encourages blood return to the chestEncourages blood return to the chest

�� Artificial ventilation is positive pressureArtificial ventilation is positive pressure

�� Reduces blood return to the chest Reduces blood return to the chest

�� High ventilation rates increase the total time the High ventilation rates increase the total time the

chest is under pressure chest is under pressure

�� The more time the chest is under pressure the The more time the chest is under pressure the

less time there is for blood return to the heart less time there is for blood return to the heart

and less time for emptying of the cerebral blood and less time for emptying of the cerebral blood

vesselsvessels

Survival in hyperventilationSurvival in hyperventilation

STOP HyperventilatingSTOP Hyperventilating

�� Harder to do than you thinkHarder to do than you think

�� Action oriented providerAction oriented provider

�� High adrenaline situationHigh adrenaline situation

�� Tendency to ventilate faster and fasterTendency to ventilate faster and faster

�� Requires conscious effort to slow ratesRequires conscious effort to slow rates

�� Need constant reminder Need constant reminder

�� Timing deviceTiming device

�� Goal directed ventilationGoal directed ventilation

…….what is our airway management .what is our airway management

device of choice in a cardiac arrest?device of choice in a cardiac arrest?

The device that allows us to The device that allows us to

oxygenateoxygenate the patients brain and the patients brain and

myocardium and causes themyocardium and causes the……

LEAST interruption in

compressions

But I donBut I don’’t interrupt CPRt interrupt CPR……

� 100 Cardiac Arrests

� CPR interruptions 2* (1-9)

� 1st ETI interruption 46.5 s* (7-221 s)

� Total all ETI interruption 109.5 s* (13-446 s)

� 1/3 > 1 min; ¼ > 3 min

� ETI Interruptions 23% of all

* Indicates median values reported

Wang et al. Interruptions in CPR from Paramedic Intubation. Ann Emerg Med. 2009

But an advanced airway is a But an advanced airway is a

better airwaybetter airway……....

TechnologyTechnology

Technology is a queer thing. It brings Technology is a queer thing. It brings

you great gifts with one hand, and it you great gifts with one hand, and it

stabs you in the back with the other. stabs you in the back with the other. Carrie P. SnowCarrie P. Snow

Advanced Airway ManagementAdvanced Airway Management

�� AdvantagesAdvantages

�� No mask seal requiredNo mask seal required

�� Easier to do Easier to do

�� Less manpowerLess manpower

�� Allows continuous compressionsAllows continuous compressions

�� DisadvantageDisadvantage

�� Requires interruption of compressionsRequires interruption of compressions

�� Easier to hyperventilate (rate and volume)Easier to hyperventilate (rate and volume)

�� DoesnDoesn’’t provide better ventilation/oxygenationt provide better ventilation/oxygenation

�� 173 LMA vs 200 BVM by paramedics173 LMA vs 200 BVM by paramedics

�� No difference in median:No difference in median:

�� Pa Pa COCO22 52.9 v 55.3 (p=0.06)52.9 v 55.3 (p=0.06)

�� Pa Pa OO22 64.6 v 71.9 (p=0.056)64.6 v 71.9 (p=0.056)

�� There is no MAGIC to these devicesThere is no MAGIC to these devices

What about IV/IO/EJ access?What about IV/IO/EJ access?

Why do we establish IV access?Why do we establish IV access?

�� 851 patients with OOHCA randomized to:851 patients with OOHCA randomized to:

�� 418 given IV drugs418 given IV drugs

�� 433 given no drugs433 given no drugs

�� Primary outcome hospital dischargePrimary outcome hospital discharge

�� Also looked at:Also looked at:

�� Hosp admission with ROSCHosp admission with ROSC

�� Neuro outcome at dischargeNeuro outcome at discharge

�� Survival at 1 yearSurvival at 1 year

IV Drugs vs No Drugs

32

10.5 9.8

21

9.28.1

0

5

10

15

20

25

30

35

ROSC D/C Good Neuro

Outcome

%

Drugs

No Drugs

One studyOne study……

does not the science make!does not the science make!

�� Must continue to evaluate the science criticallyMust continue to evaluate the science critically

�� Maintains perspective on value of interventionMaintains perspective on value of intervention

�� Assists in establishing prioritiesAssists in establishing priorities

OOHCA What matters!OOHCA What matters!

�� For first 3 cycles concentrate on For first 3 cycles concentrate on compressionscompressions

�� Get on the chest as quick as possibleGet on the chest as quick as possible

�� Compress hard and fastCompress hard and fast

�� Minimize interruptions Minimize interruptions

�� If on monitor compress up to delivery of shockIf on monitor compress up to delivery of shock

�� Resume compressions immediately regardless of pulse or Resume compressions immediately regardless of pulse or

rhythmrhythm

�� BVM BVM ONLYONLY

�� Control ventilation (use your blinky light)Control ventilation (use your blinky light)


�� After 3 cycles (6 min) place King AirwayAfter 3 cycles (6 min) place King Airway

�� DonDon’’t stop compressions!t stop compressions!

�� ETI only if unsuccessful with BIADETI only if unsuccessful with BIAD

�� Place gastric tube via KING or OG/NGPlace gastric tube via KING or OG/NG

�� Control your ventilationsControl your ventilations

�� If patient is Asystole/PEA may place airwayIf patient is Asystole/PEA may place airway

�� Recheck tube with each patient movementRecheck tube with each patient movement


�� Continue resuscitation Continue resuscitation

�� Rhythm/Pulse check Rhythm/Pulse check onlyonly at 2 min at 2 min

�� Change compressor q 2 min regardless of fatigueChange compressor q 2 min regardless of fatigue

�� Run checklist to assure overlooked errorsRun checklist to assure overlooked errors

�� Careful consideration of causesCareful consideration of causes

�� Do NOT move the patient unless:Do NOT move the patient unless:

�� You are in potential dangerYou are in potential danger

�� You are in a public placeYou are in a public place

�� Other situation not suitable to leave the bodyOther situation not suitable to leave the body

Induced Hypothermia

� Do NOT delay starting IH

� If patient meets inclusion criteria start cooling

� Do not worry about rewarming

Time Dependent ConditionsTime Dependent Conditions

StrokeStroke

85 year old female with altered mental status and 85 year old female with altered mental status and

left sided weakness.left sided weakness.

�� Location Location –– left sided weaknessleft sided weakness

�� OOnset nset –– suddensudden

�� PPrecipitating event(s) recipitating event(s) –– was eating breakfast was eating breakfast

�� QQuality uality –– N/AN/A

�� RRadiation adiation –– affects entire left side affects entire left side

�� SSeverity everity –– unable to move or speak clearlyunable to move or speak clearly

�� TTime/Durationime/Duration-- 30 min prior to arrival30 min prior to arrival

�� Aggravating/Alleviating Aggravating/Alleviating –– nothingnothing

�� Associated symptoms Associated symptoms –– slurred speech, canslurred speech, can’’t t follow commands, left sided weaknessfollow commands, left sided weakness


What is the differential?What is the differential?


�� Vascular Vascular –– hemorrhagic stroke, nonhemorrhagic stroke, non--hemorrhagic hemorrhagic stroke, shockstroke, shock

�� Infectious / inflammatory Infectious / inflammatory –– Intracranial infection, Intracranial infection, sepsis, encephalopathysepsis, encephalopathy

�� Trauma / ToxinsTrauma / Toxins-- drug overdose, alcohol, head traumadrug overdose, alcohol, head trauma

�� Autoimmune Autoimmune –– N/AN/A

�� Metabolic Metabolic –– hypo/hyperglycemia, hypoxia, dehydration, hypo/hyperglycemia, hypoxia, dehydration, heat stroke, hypothermia, uremia, thyroid d/o, seizureheat stroke, hypothermia, uremia, thyroid d/o, seizure

�� Idiopathic Idiopathic –– psychiatric, psychiatric,

�� Neoplastic Neoplastic –– brain tumorbrain tumor

�� Congenital Congenital –– N/AN/A

Altered Mental StatusAltered Mental Status

�� AA-- alcoholalcohol

�� EE-- epilepsy (seizure)epilepsy (seizure)

�� II-- infection, inflammation infection, inflammation

�� OO-- oxygen (hypooxygen (hypo--))

�� UU-- uremiauremia

�� T T –– trauma, toxins, temperature, trauma, toxins, temperature,

�� I I -- insulininsulin

�� P P -- psychosispsychosis

�� S S –– stroke, space occupying lesion, shock (hypotension)stroke, space occupying lesion, shock (hypotension)

Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke Scale

Stroke :What mattersStroke :What matters

�� Identification Identification

�� When it startedWhen it started

�� Treatable mimickers (hypoglycemia)Treatable mimickers (hypoglycemia)

�� InstitutionInstitution

�� Early notificationEarly notification

�� Appropriate destinationAppropriate destination

�� InterventionIntervention

�� Short scene interval < 15 minShort scene interval < 15 min

�� Thrombolytic checklistThrombolytic checklist

Essential Stroke ElementsEssential Stroke Elements

�� Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke Scale

�� Finger stick blood glucoseFinger stick blood glucose

�� Exact time of onset (when last seen normal)Exact time of onset (when last seen normal)

�� NotificationNotification

�� Short scene intervalShort scene interval

�� Identify someone to accompany to hospitalIdentify someone to accompany to hospital

What you donWhat you don’’t seet see

�� IVIV

�� EKGEKG

�� These do not change the outcomeThese do not change the outcome

�� These lengthen scene timesThese lengthen scene times

�� Do these enroute to the hospitalDo these enroute to the hospital

STEMISTEMI

85 year old complaining of chest pain.85 year old complaining of chest pain.


�� Location Location –– left chestleft chest

�� OOnset nset –– suddensudden

�� PPrecipitating event(s) recipitating event(s) –– sweeping the kitchen sweeping the kitchen

�� QQuality uality –– pressurepressure

�� RRadiation adiation –– left arm, neck left arm, neck

�� SSeverity everity –– 99

�� TTime/Durationime/Duration-- 30 min PTA30 min PTA

�� Aggravating/Alleviating Aggravating/Alleviating –– worse with walking or exertion worse with walking or exertion improves some with restingimproves some with resting

�� Associated symptoms Associated symptoms –– sweaty, racing heart, lightheaded, short sweaty, racing heart, lightheaded, short of breath, nauseaof breath, nausea



�� Vascular : MI, Pulmonary embolus, thoracic aneurysm,Vascular : MI, Pulmonary embolus, thoracic aneurysm,

�� Infectious / inflammatory: pneumonia, pleurisy, Infectious / inflammatory: pneumonia, pleurisy, pericarditis, gastritis, billiary diseasepericarditis, gastritis, billiary disease

�� Trauma / Toxins: rib fracture, tension pneumothorax, Trauma / Toxins: rib fracture, tension pneumothorax, carbon monoxidecarbon monoxide

�� Autoimmune: N/AAutoimmune: N/A

�� Metabolic: Metabolic:

�� Idiopathic: pneumothoraxIdiopathic: pneumothorax

�� Neoplastic: Lung CA, thoracic outlet syndromeNeoplastic: Lung CA, thoracic outlet syndrome

�� Congenital: NACongenital: NA

STEMI: What mattersSTEMI: What matters


�� Rapid acquisition of EKGRapid acquisition of EKG

�� Rapid interpretationRapid interpretation


�� Early notification (once identified)Early notification (once identified)



�� Short scene interval <15 minShort scene interval <15 min

�� Aspirin and oxygenAspirin and oxygen

What you donWhat you don’’t seet see

�� NTGNTG

�� Provides symptomatic reliefProvides symptomatic relief

�� Does not convey survival benefitDoes not convey survival benefit

�� Do not treat low BP only to give NTG Do not treat low BP only to give NTG

�� IVIV

�� Used to treat BP (see above)Used to treat BP (see above)

�� These do not change the outcomeThese do not change the outcome

�� These lengthen scene timesThese lengthen scene times

IV and NTG Bad?IV and NTG Bad?

�� This does not mean that it is badThis does not mean that it is bad

�� Understand what is importantUnderstand what is important

�� Actual treatment is in a cath labActual treatment is in a cath lab

�� DO NOT delay on sceneDO NOT delay on scene

�� Give NTG when their BP will tolerateGive NTG when their BP will tolerate

�� Maintain coronary perfusing pressureMaintain coronary perfusing pressure

�� Start an IV when time permitsStart an IV when time permits

TraumaTrauma

85 year old male single occupant driver of vehicle 85 year old male single occupant driver of vehicle

that struck a telephone pole in a corner. There that struck a telephone pole in a corner. There

were no other vehicles involved. The patient is were no other vehicles involved. The patient is

unconscious.unconscious.

What else do you want to know?What else do you want to know?

Trauma AssessmentTrauma Assessment

�� Physical exam has increased importancePhysical exam has increased importance

�� Goal is rapid identification and treatment of Goal is rapid identification and treatment of

LIFE THREATENING injury.LIFE THREATENING injury.

�� Are they sick or not sickAre they sick or not sick

�� Is not a comprehensive examIs not a comprehensive exam

�� DonDon’’t diagnose what you cant diagnose what you can’’t treatt treat

Treatable (prehospital)Treatable (prehospital)

Life Threats in Trauma?Life Threats in Trauma?

�� All can be found with primary assessmentAll can be found with primary assessment

�� All can be treated in primary assessmentAll can be treated in primary assessment

�� There are really not that manyThere are really not that many

�� Interventions are BASICInterventions are BASIC

�� Treatment is surgical!Treatment is surgical!


�� AirwayAirway

�� BreathingBreathing

�� CirculationCirculation

�� DisabilityDisability

�� ExposeExpose

AirwayAirway

�� Look in the mouthLook in the mouth

�� ListenListen

�� GurglingGurgling

�� Voice changesVoice changes

�� StridorStridor

�� Feel Feel –– Not so muchNot so much

�� If they are talking to you ask to say ahhhhIf they are talking to you ask to say ahhhh

�� If they can do that their airway is intact (and they If they can do that their airway is intact (and they follow commands)follow commands)

Airway InterventionsAirway Interventions

�� Suction as neededSuction as needed

�� Initiate BLS airway interventionInitiate BLS airway intervention

�� OPAOPA

�� NPANPA

�� Initiate oxygenInitiate oxygen

Airway Management PrioritiesAirway Management Priorities

1.1. OxygenateOxygenate

2.2. VentilateVentilate

3.3. Protect AirwayProtect Airway

Airway ManagementAirway Management

�� Always start with a basic airwayAlways start with a basic airway

�� Utilize only as much as needed to meet the Utilize only as much as needed to meet the

objective objective

Failed AirwayFailed Airway

�� Is the inability to oxygenate!Is the inability to oxygenate!

�� If you are unable to oxygenate they will die soonIf you are unable to oxygenate they will die soon

�� If you are unable to oxygenate Sat >89% If you are unable to oxygenate Sat >89%

�� Make sure you are delivering 100% oxygenMake sure you are delivering 100% oxygen

�� Place OPA and 2 NPAPlace OPA and 2 NPA

�� BIAD/ETT attemptBIAD/ETT attempt

�� If despite all these things you are unable to If despite all these things you are unable to

oxygenate you have a FAILED AIRWAYoxygenate you have a FAILED AIRWAY

What is management tool for What is management tool for

failed airway?failed airway?

�� CricothyrotomyCricothyrotomy

�� Not benign procedureNot benign procedure

�� Moving to percutaneous techniqueMoving to percutaneous technique

�� If you can oxygenate you have TIMEIf you can oxygenate you have TIME

�� Cricothyrotomy is not indicated to Cricothyrotomy is not indicated to ““securesecure”” an an

airwayairway

Scalpel UseScalpel Use

Vertical Incision AnatomyVertical Incision Anatomy

A quick word on airwayA quick word on airway

�� If they are actively vomiting TURN THEMIf they are actively vomiting TURN THEM

�� Suction will not keep up with volume Suction will not keep up with volume

�� If they are alert, upright If they are alert, upright andand managing an at risk managing an at risk

airway all by themselvesairway all by themselves…………

�� DO NOT FORCE THEM TO LAY SUPINEDO NOT FORCE THEM TO LAY SUPINE

BreathingBreathing

�� Expose the chestExpose the chest

�� Look:Look:�� At the anterior neck for trauma, JVDAt the anterior neck for trauma, JVD

�� At the chest wall for At the chest wall for �� Estimate of rate (fast, slow, normal)Estimate of rate (fast, slow, normal)

�� Contusions, obvious deformity, sucking chest woundContusions, obvious deformity, sucking chest wound

�� Listen for breath sounds (equality only)Listen for breath sounds (equality only)

�� FeelFeel�� Squish or crunchSquish or crunch

�� Equal chest riseEqual chest rise

Breathing InterventionBreathing Intervention

�� Oxygen if not already appliedOxygen if not already applied

�� BVM if breathing effort is not adequateBVM if breathing effort is not adequate

CirculationCirculation

�� Look at the exposed abdomen and pelvis:Look at the exposed abdomen and pelvis:�� Obvious bleeding, deformity or traumaObvious bleeding, deformity or trauma

�� Skin color, Abdominal wall for contusion, flank hematomaSkin color, Abdominal wall for contusion, flank hematoma

�� Listen Listen –– not so muchnot so much

�� FeelFeel�� PresencePresence of pulse (Radial then Femoral then Carotid)of pulse (Radial then Femoral then Carotid)

�� Fast, slow, normalFast, slow, normal

�� AbdomenAbdomen

�� PelvisPelvis

�� FemursFemurs

�� Look MaLook Ma…….no blood pressure.no blood pressure

Circulation : A word on bleedingCirculation : A word on bleeding

�� People bleed to death from very predictable sourcesPeople bleed to death from very predictable sources

�� ChestChest

�� AbdomenAbdomen

�� PelvisPelvis

�� Long bonesLong bones

�� Outside worldOutside world

�� IV/IOIV/IO

�� IVs do not save peopleIVs do not save people

�� DO NOT delay transport to establish IVsDO NOT delay transport to establish IVs

DisabilityDisability

�� AVPU / GCSAVPU / GCS

�� MotorMotor

�� ““Wiggle your hands and feetWiggle your hands and feet””

�� PupilsPupils

�� If unable to follow commandsIf unable to follow commands

Glasgow Coma ScoreGlasgow Coma ScoreGlasgow Coma Score

Disability InterventionsDisability Interventions

�� Collar and spinal immobilizationCollar and spinal immobilization

�� Airway managementAirway management

�� OxygenationOxygenation

�� Bleeding control (to prevent hypotension)Bleeding control (to prevent hypotension)

ExposeExpose

�� Naked is your friendNaked is your friend

�� LOOK head to toeLOOK head to toe

�� Identify anything funkyIdentify anything funky

�� Most injuries found here you wonMost injuries found here you won’’t treat but t treat but

should probably noteshould probably note

Successful Trauma MgtSuccessful Trauma Mgt

�� This is directly contrary to everything else we doThis is directly contrary to everything else we do

�� Requires speed, efficiency and focusRequires speed, efficiency and focus

�� Brain change Brain change –– FIX only what mattersFIX only what matters

�� Low comfort levelLow comfort level……sick but not fixablesick but not fixable

�� Must disregard many things that are brokenMust disregard many things that are broken

�� Secondary assessment doesnSecondary assessment doesn’’t exist if they are t exist if they are sicksick

Successful Trauma MgtSuccessful Trauma Mgt

�� Systematic approachSystematic approach

�� Delegation of dutiesDelegation of duties

�� Fix only what mattersFix only what matters

Systematic ApproachSystematic Approach

�� Do it the same way every timeDo it the same way every time

�� Do it right the first timeDo it right the first time

�� If need to intervene immediately complete If need to intervene immediately complete intervention and then resume systematic intervention and then resume systematic approachapproach

�� If you find something you canIf you find something you can’’t definitively fix, t definitively fix, make note of it and move onmake note of it and move on

�� Delegate what needs fixing when you canDelegate what needs fixing when you can

The list of what we can fix is small!The list of what we can fix is small!

�� Airway: direct trauma, unstable/at riskAirway: direct trauma, unstable/at risk�� Suction, BLS airway, oxygenSuction, BLS airway, oxygen

�� Breathing: Hypoxia, sucking CW, TPTX Breathing: Hypoxia, sucking CW, TPTX �� Oxygen/BVM PRN, occlusive dressing, needle decompressionOxygen/BVM PRN, occlusive dressing, needle decompression

�� Circulation: ext hem, pelvic fracture, fractureCirculation: ext hem, pelvic fracture, fracture�� Direct pressure, tourniquet, pelvic binder, immobilize fractureDirect pressure, tourniquet, pelvic binder, immobilize fracture

�� Disability: none Disability: none –– prevent secondary injuryprevent secondary injury�� Immobilize, oxygenImmobilize, oxygen

�� ExposeExpose�� Fractures found here are immobilized with spine boardFractures found here are immobilized with spine board

Severe Trauma: What MattersSevere Trauma: What Matters


�� Trauma CriteriaTrauma Criteria


�� Early notification Early notification



�� Gain accessGain access

�� Treat life threatsTreat life threats

�� Transport!!!!Transport!!!!

TourniquetsTourniquets


�� Have been in use since the RomansHave been in use since the Romans

�� Prohibitions against use have reached mythical Prohibitions against use have reached mythical

proportionsproportions

�� This despite being the standard of care in This despite being the standard of care in

surgery and in combat theatres around the worldsurgery and in combat theatres around the world

�� CanCan’’t be safely used by EMS?t be safely used by EMS?

�� This defies common senseThis defies common sense


�� Penetrating trauma can cause life threatening Penetrating trauma can cause life threatening

extremity traumaextremity trauma

�� VietnamVietnam--38% of soldiers who died from extremity 38% of soldiers who died from extremity

trauma could have been savedtrauma could have been saved

�� Modern ballistics protection increases likelihood Modern ballistics protection increases likelihood

of death due to extremity traumaof death due to extremity trauma

�� Are now standard issues for EVERY combat Are now standard issues for EVERY combat

soldiersoldier

Military ABCMilitary ABC’’ss

�� MM-- Massive bleedingMassive bleeding

�� A A –– AirwayAirway

�� RR-- RespirationsRespirations

�� CC-- CirculationCirculation

�� HH-- Head InjuryHead Injury

�� Isolated extremity trauma who arrived deadIsolated extremity trauma who arrived dead

�� 14 of 75,000 trauma center patients14 of 75,000 trauma center patients

�� 50% GSW50% GSW

�� 71% LE 86% proximal to elbow or knee71% LE 86% proximal to elbow or knee

�� 86% had signs of life in the field86% had signs of life in the field

�� 9/14 underwent thoracotomy9/14 underwent thoracotomy

�� There were no survivorsThere were no survivors

J Trauma 2005; 59:217-22.

Tourniquets: Civilian EMSTourniquets: Civilian EMS

�� Must be used appropriatelyMust be used appropriately

�� Improvised devices are less effective and cause Improvised devices are less effective and cause

more complicationsmore complications

�� Quickly stops hemorrhage to allow other life Quickly stops hemorrhage to allow other life

saving interventionssaving interventions

�� Can be reassessed after placementCan be reassessed after placement

�� Requires training and PI reviewRequires training and PI review

�� Requires education of receiving facilitiesRequires education of receiving facilitiesDoyle G, Taillac P. Tourniquets: A Review of Current Use with

Proposals for Expanded Prehospital use. PEC 2008; 12:241-56.

Combat Applied TourniquetCombat Applied Tourniquet

Respiratory Distress

Scenario

38 year old female complaining of severe SOB speaking in 2-3 word sentences. States it began suddenly approximately 20 min ago after playing with friends dog. Has used rescue inhaler x 4 without relief. Similar episode in the past with exposure to dogs. Denies additional symptoms

T 98.3 R36 P 130 BP 130/84 SaO2 90% ETCO2 37

Alert but anxious appearing. Obvious distress, tripod position with supraclavicular retractions and accessory mm use. BS quiet bilat with faint end expiratory wheeze and prolonged exhalation.

Differential

� Vascular

� Infectious / inflammatory

� Trauma / Toxins

� Autoimmune

� Metabolic

� Idiopathic

� Neoplastic

� Congenital

Asthma

� Is an obstructive disorder characterized by increased airway resistance due to:

� Bronchoconstriction

� Inflammation

� Bronchorrhea

� Resistance must be overcome in both the inspiratory phase and expiratory phase

Increased Airway Resistance

� Increased work of breathing

� Overcome resistance on inspiration

� Exhalation becomes ACTIVE

� Asthmatics get into trouble when:

� Respiratory muscles fatigue (decreased ventilation)

� No longer able to oxygenate

Scenario

38 year old female complaining of severe SOB speaking in 2-3 word sentences. States it began suddenly approximately 20 min ago after playing with friends dog. Has used rescue inhaler x 4 without relief. Similar episode in the past with exposure to dogs. Denies additional symptoms

T:98.7 R: 20 P: 100 BP: 100/70 Pox: 90% ETCO2: 50

Somnolent, obvious distress, tripod position, supraclavicular retractions and accessory mm usage. BS quiet bilat with faint end expiratory wheeze, and prolonged exhalation.

Asthma Treatment

� Mild – Moderate

� Inhaled beta agonist/anticholinergic w/ supplemental oxygen

� Severe (poor air movement, SaO2 <91%)

� Inhaled beta agonist/anticholinergic w/ supplemental oxygen

� CPAP

� Respiratory failure (somnolence, poor effort)

� Assist ventilation (carefully!)

� BVM beta agonist

Asthma Treatment

� Oxygenation is first goal!

� Reduce airway resistance

� Bronchodilators (smooth mm relaxers)

� Anticholinergics (decrease bronchorrhea)

� Prevent respiratory failure

� Then….. reverse any hypercarbia

Continuous Positive Airway Pressure

� CPAP originally thought to be bad in Asthma

� Low CPAP setting 5-7 cm H2O may be helpful

� Consider that:

� Patients will often not tolerate

� Venturi device delivers max 30% O2

� If not tolerating or Sats remain low after brief trial return to NRFM or move to BVM

A Word on Assisted Ventilation

� Disease process causes air trapping

� Prolonged exhalation phase

� Lung hyperinflation

� Increased intrathoracic pressure

� Decreased blood return to the heart

� What respiratory rate should you target?

� It depends!

� How long does it take them to exhale

Assisted Ventilations

� Assisted ventilation must allow for exhalation

� Natural tendency is to hyperventilate

� High stress

� Multiple distractions

� Decreased blood return causes cardiac arrest

� Time ventilations to exhalation

� Watch chest fall

� Listen with stethoscope

Remember initial goal is to

OXYGENATE

until bronchospasm can be reversed

How About COPD

� Chronic Bronchitis and Emphysema � Chronic compromise of lung function with low oxygen states

� Underlying disease is irreversible

� Chronic condition is punctuated by episodes (reversible) of increased airway resistance and air trapping

� Acute events typically triggered by environmental exposure or URI

Assessing Severity

� More difficult in COPD

� End stages of disease

� Chronic hypoxia

� Poor air movement

� Chronic hypercarbia

� Often best measure is patient themselves

� Ask about severity

� Ask about fatigue

Treatment of COPD

� Treatment priorities are similar to asthma

� Oxygenate

� Reduce airway resistance

� Bronchodilators

� Anticholinergics

� Prevent or treat respiratory failure

� Then work to improve hypercarbia

COPD Treatment

� Mild – Moderate

� Inhaled beta agonist w/ supplemental oxygen

� Severe

� Inhaled beta agonist w/ supplemental oxygen

� CPAP

� Respiratory failure (somnolence)

� Assist ventilation (carefully!)

� BVM beta agonist

CPAP in COPD

� Retrospective observational study

� 237 patients with resp failure admitted to the ICU

� Comparison of CPAP to traditional medical therapy

Dial S et al. Is there a role for mask continuous positive airway pressure in acute respiratory failure due to COPD? Lessons from a retrospective audit of 3 different cohorts. Int J Chron Obstruct Pulmon Dis. 2006;1(1):65-72

CPAP in COPD

� Progressed to intubation

� 16% in CPAP vs 62% in traditional

� Avoid Intubation!

� Mortality if early ETI OR 15.7

� Mortality medical mgt OR 5.1

� ICU Stay

� CPAP 5 days

� Medical 7 days

� Intubated 8.5 days

Congestive Heart Congestive Heart

FailureFailure

ScenarioScenario

42 y/o male with history of poorly controlled 42 y/o male with history of poorly controlled hypertension has complaint of severe chest pain which hypertension has complaint of severe chest pain which began yesterday lasting several hours and was began yesterday lasting several hours and was associated with mild shortness of breath. Pain has associated with mild shortness of breath. Pain has resolved but since that time he has developed gradually resolved but since that time he has developed gradually worsening severe shortness of breath made worse with worsening severe shortness of breath made worse with lying down and exertion. Improves with sitting up. lying down and exertion. Improves with sitting up. Now to the point of sleeping in chair. Has noticed Now to the point of sleeping in chair. Has noticed some significant swelling in his legs and associated pain. some significant swelling in his legs and associated pain. Has never had anything like this in the past. Has not Has never had anything like this in the past. Has not been taking his medication for months because of the been taking his medication for months because of the loss of his job.loss of his job.

Systolic vs Diastolic HFSystolic vs Diastolic HF

�� Systolic HF (65Systolic HF (65--75%)75%)�� Reduced EFReduced EF

�� Decreased emptyingDecreased emptying

�� Dilated cardiomyopathy, MIDilated cardiomyopathy, MI

�� Very afterload sensitiveVery afterload sensitive

�� Diastolic HFDiastolic HF�� Preserved EFPreserved EF

�� Decreased fillingDecreased filling

�� Restrictive/Hypertrophic cardiomyopathy, HTN, Restrictive/Hypertrophic cardiomyopathy, HTN, AmyloidosisAmyloidosis

�� Very preload sensitiveVery preload sensitive

Pathophysiology of CHFPathophysiology of CHF

�� Weak pump (LV) causes decreased blood flow Weak pump (LV) causes decreased blood flow

to kidneysto kidneys

�� Kidneys are selfishKidneys are selfish-- like blood flowlike blood flow

�� Need pressure to drive flow in kidneyNeed pressure to drive flow in kidney

�� Kidney increases vasoconstriction to increase Kidney increases vasoconstriction to increase

pressure and blood flowpressure and blood flow

�� Increased vasoconstriction increases resistance Increased vasoconstriction increases resistance

to flow and strain on LV (afterload)to flow and strain on LV (afterload)

CHFCHF

�� Fundamental problem is increased afterloadFundamental problem is increased afterload

�� > 50% of severely decompensated CHF do > 50% of severely decompensated CHF do

NOT have volume overloadNOT have volume overload

�� Problem is maldistribution of volumeProblem is maldistribution of volume

�� Made worse by misdiagnosis rates 15Made worse by misdiagnosis rates 15--45%45%

�� Pneumonia, sepsis, COPD, dehydrationPneumonia, sepsis, COPD, dehydration

CHF=Bad PumpCHF=Bad Pump

�� Fundamental problem is increased afterloadFundamental problem is increased afterload

�� Bad pump can not push against increased resistanceBad pump can not push against increased resistance

�� Leaves fluid behind in lungs (wet lungs)Leaves fluid behind in lungs (wet lungs)

�� Affects gas exchangeAffects gas exchange

�� Causes atelectasisCauses atelectasis

�� Acute CHF has misdiagnosis rates 15Acute CHF has misdiagnosis rates 15--45%45%

�� Pneumonia, sepsis, COPD, dehydrationPneumonia, sepsis, COPD, dehydration

�� All that crackles is not CHFAll that crackles is not CHF

�� All that wheezes is not asthma/COPDAll that wheezes is not asthma/COPD

What is your CHF Cocktail?What is your CHF Cocktail?

�� NTG?NTG?

�� Lasix?Lasix?

�� Morphine?Morphine?

�� Albuterol?Albuterol?

LasixLasix--Stop the madness!Stop the madness!

�� Renal perfusion is compromisedRenal perfusion is compromised

�� Poor flow = poor filtration=poor diuresisPoor flow = poor filtration=poor diuresis

�� Effect delayed 90Effect delayed 90--120 min120 min

�� Lasix is not in helpful in acute management!Lasix is not in helpful in acute management!

�� Causes electrolyte abnormalitiesCauses electrolyte abnormalities

�� >25% required fluid replacement>25% required fluid replacement

�� Lasix is harmful in misdiagnosisLasix is harmful in misdiagnosis

�� NTG only 2.2% mortalityNTG only 2.2% mortality

�� Lasix/Morphine 21.7% mortalityLasix/Morphine 21.7% mortality

How about morphine?How about morphine?

�� Useful as anxiolytic?Useful as anxiolytic?

�� PrePre--load reduction?load reduction?

�� Causes transient increase increase in preCauses transient increase increase in pre--load and load and

cardiac suppressioncardiac suppression

�� Morphine use(Sacchetti)Morphine use(Sacchetti)

�� Associated with 5 fold increase in ICU use and Associated with 5 fold increase in ICU use and

intubationintubation

�� DonDon’’t use morphine!t use morphine!

How should you treat?How should you treat?

�� OxygenOxygen-- remember oxygenation is GOODremember oxygenation is GOOD

�� NTGNTG-- to reduce afterload (hold if SBP<100) to reduce afterload (hold if SBP<100)

�� Position with legs dependent Position with legs dependent

�� CPAPCPAP

�� 95 patients with standard therapy95 patients with standard therapy

�� O2, nitrates, lasix, morphine, ETI PRNO2, nitrates, lasix, morphine, ETI PRN

�� 120 patients with CPAP + standard120 patients with CPAP + standard

�� CPAP at 10cm H20CPAP at 10cm H20

Effect of CPAP in CHFEffect of CPAP in CHF

Intubated OR 4.04 Death OR 7.48

SedationSedation

�� Anxiolytics may sometimes be needed to help Anxiolytics may sometimes be needed to help

patients tolerate CPAPpatients tolerate CPAP

�� Use them cautiously!Use them cautiously!

�� An overly sedated patient can not use CPAPAn overly sedated patient can not use CPAP

�� Anxiolytics should be used with extreme caution Anxiolytics should be used with extreme caution

in patients with a c/o SOBin patients with a c/o SOB

�� Anxiety is a diagnosis of exclusion Anxiety is a diagnosis of exclusion

�� SOB should not be treated as anxiety SOB should not be treated as anxiety

Pain ManagementPain Management

�� Numerous complaints from patients /physiciansNumerous complaints from patients /physicians

�� Use pain management appropriatelyUse pain management appropriately

�� Some patients will not be pain freeSome patients will not be pain free

�� Ask if they want/want more pain medsAsk if they want/want more pain meds

�� Fentanyl Fentanyl

�� 1mcg/kg IV first dose and 0.5 mcg/kg subsequent1mcg/kg IV first dose and 0.5 mcg/kg subsequent

�� Use w/caution in the elderlyUse w/caution in the elderly

AnaphylaxisAnaphylaxis

Scenario #1Scenario #1

You are called to for a 38 y/o construction worker You are called to for a 38 y/o construction worker

stung by a bee approximately twenty minutes stung by a bee approximately twenty minutes

before calling 911. He has localized swelling, before calling 911. He has localized swelling,

itching with redness and hives on his arms and itching with redness and hives on his arms and

trunk and facial swelling, shortness of breath, mild trunk and facial swelling, shortness of breath, mild

tightness in chest and slight wheeze. He has no tightness in chest and slight wheeze. He has no

lightheadedness or syncope. He denies any prior lightheadedness or syncope. He denies any prior

allergic reactions, and has a history of asthma. His allergic reactions, and has a history of asthma. His

only medication is alubuterol PRN.only medication is alubuterol PRN.

Pathophysiology of AllergyPathophysiology of Allergy

�� Exposure to an antigen (allergen)Exposure to an antigen (allergen)

�� Oral ingestionOral ingestion

�� InjectionInjection

�� EnvenomationEnvenomation

�� InhalationInhalation

�� Skin (topical)Skin (topical)

So what happens?So what happens?

�� Exposure triggers release of chemical Exposure triggers release of chemical

messengersmessengers

�� HistaminesHistamines

�� Quick release / Short actingQuick release / Short acting

�� LeukotrienesLeukotrienes

�� Slow release / Long actingSlow release / Long acting

Histamines and LeukotrienesHistamines and Leukotrienes

�� Pruritis (itching) and Urticaria (hives)Pruritis (itching) and Urticaria (hives)

�� BronchoconstrictionBronchoconstriction

�� Airway inflammationAirway inflammation

�� VasodilatationVasodilatation

�� Vascular permeabilityVascular permeability

�� GI smooth muscle contractionGI smooth muscle contraction

Subsequent Exposures!Subsequent Exposures!

�� How fast?How fast?

�� Route and rateRoute and rate

�� Volume of allergenVolume of allergen

�� Host sensitivityHost sensitivity

�� Most within 30Most within 30--60 min60 min

�� Faster Faster the reaction the the reaction the more severemore severe

�� Speed of onset of prior reactionSpeed of onset of prior reaction

Why are allergic reactions scary?Why are allergic reactions scary?

We donWe don’’t knowt knowHow bad it will get?How bad it will get?

How aggressive we should be?How aggressive we should be?

SoSo

Have to act quicklyHave to act quickly……....

But with very little information!But with very little information!

Where do I start?Where do I start?

�� Start your PrimaryStart your Primary

�� HISTORYHISTORY

�� Is this a known exposure?Is this a known exposure?

�� How did they react last time?How did they react last time?

�� Route of exposure and how much? Route of exposure and how much?

�� How fast has this progressed? How fast has this progressed?

�� Have they taken anything for the reaction?Have they taken anything for the reaction?

�� Treat as you goTreat as you go

What is the most What is the most

common cause of common cause of

allergic reactions?allergic reactions?

Or these guys?Or these guys?

What are the causes?What are the causes?

�� True incidence is unknownTrue incidence is unknown

�� Formerly lacked clear definition Formerly lacked clear definition –– likely under likely under

reportedreported

�� One study estimatedOne study estimated

�� Allergic reaction .5% (5 per 1000)Allergic reaction .5% (5 per 1000)

�� Anaphylaxis .02% (2 per 10,000)Anaphylaxis .02% (2 per 10,000)

�� NationwideNationwide

�� 4 fatalities per 10 million people4 fatalities per 10 million people

Leading CausesLeading Causes

�� HymenopteraHymenoptera

�� Bees, wasps, yellow jacket, etcBees, wasps, yellow jacket, etc

�� Hymenoptera fewer than 100 deaths per yearHymenoptera fewer than 100 deaths per year

�� MedicationsMedications

�� Increasing number of medication reactionsIncreasing number of medication reactions

�� Antibiotics 100 Antibiotics 100 --500 deaths per year 500 deaths per year

�� Food Allergies also on the riseFood Allergies also on the rise

�� Account for 30,000 ED visits/yearAccount for 30,000 ED visits/year

�� 150150--200 deaths per year200 deaths per year

Is our patient anaphylactic?Is our patient anaphylactic?

Definition of AnaphylaxisDefinition of Anaphylaxis

�� Historically unclearHistorically unclear

�� Variability amongst practitioners and publicVariability amongst practitioners and public

�� Difficult to treat or study what you canDifficult to treat or study what you can’’t t

describedescribe

�� Food Allergy and Anaphylaxis Network Food Allergy and Anaphylaxis Network

(FAAN) and National Institute of Allergy and (FAAN) and National Institute of Allergy and

Infectious Disease (NIAID) definition in 2005Infectious Disease (NIAID) definition in 2005

For ProvidersFor Providers

TreatmentTreatment

�� Based on severity of reactionBased on severity of reaction

�� Limit continued exposureLimit continued exposure

�� FluidsFluids

�� Medications counteract inflammatory mediatorsMedications counteract inflammatory mediators�� EpinephrineEpinephrine

�� ββ22 AgonistsAgonists

�� Antihistamines Antihistamines

Limit Exposure!!!!Limit Exposure!!!!

�� The more allergen the greater the reactionThe more allergen the greater the reaction

�� Identify the route of exposure and remove Identify the route of exposure and remove

offending agent if possibleoffending agent if possible

�� If there is a stingerIf there is a stinger

�� Place the limb in a dependent positionPlace the limb in a dependent position

�� Scrape out stinger with firm edged objectScrape out stinger with firm edged object

�� DONDON’’T SqueezeT Squeeze

Stingers!!Stingers!!

�� Sack at base of barb Sack at base of barb

contains venomcontains venom

�� Smooth muscles Smooth muscles

continue to inject venom continue to inject venom

up to 20 minutes after up to 20 minutes after

the initial injectionthe initial injection

Treatment AvailableTreatment Available

�� OxygenOxygen

�� EpiEpi--penspens

�� Hypotensive, respiratory distress, airway affectedHypotensive, respiratory distress, airway affected

�� Beta 2 Agonists Beta 2 Agonists –– Inhalers/nebulizersInhalers/nebulizers

�� AntiAnti--histamineshistamines

�� IV/IM/PO BenadrylIV/IM/PO Benadryl

�� IV FluidsIV Fluids

ALS TreatmentsALS Treatments

�� Epinephrine IM or IVEpinephrine IM or IV

�� FluidsFluids

�� IV antihistaminesIV antihistamines

�� SolumedrolSolumedrol

�� Other vasopressorsOther vasopressors

�� Continuous nebulized Beta 2 agonistsContinuous nebulized Beta 2 agonists

When to utilize what?When to utilize what?

�� Hives onlyHives only

�� BenadrylBenadryl

�� Mild to moderate respiratory only*Mild to moderate respiratory only*

�� Benadryl and nebsBenadryl and nebs

�� Severe respiratory or hypotensionSevere respiratory or hypotension

�� EpiEpi--penpen, then Benadryl and nebs , then Benadryl and nebs

�� Consider additional use of epi and nebsConsider additional use of epi and nebs

* If associated with significant facial swelling consider Epi-pen

Why epinephrine?Why epinephrine?

�� Counters many of the symptoms in anaphylaxisCounters many of the symptoms in anaphylaxis

�� EffectsEffects

�� αα vasoconstrictionvasoconstriction

�� ββ11 increased chronotropy and inotropyincreased chronotropy and inotropy

�� ββ22 bronchodilationbronchodilation

Why the reluctance?Why the reluctance?

�� Concern for side effectsConcern for side effects

�� Dramatically increases vascular toneDramatically increases vascular tone

�� Dramatically increases myocardial workDramatically increases myocardial work

�� Side effects are greatly overstated for most Side effects are greatly overstated for most

�� Concerns in patients with CVDConcerns in patients with CVD

�� Severe adverse reactions seen almost exclusively Severe adverse reactions seen almost exclusively

with IV route of administrationwith IV route of administration

EpinephrineEpinephrine

�� IMIM in in lateral thighlateral thigh is route of administrationis route of administration

�� In healthy volunteers SQ absorption into central In healthy volunteers SQ absorption into central

circulation is significantly slower than IMcirculation is significantly slower than IM

�� Deltoid is significantly slower than thighDeltoid is significantly slower than thigh

�� Multiple doses may be required(16Multiple doses may be required(16--35%)35%)

Simmons J Allergy Clin Immun 2008

Another Scenario to ReviewAnother Scenario to Review

�� 39 y/o male with SOB for 7 hrs39 y/o male with SOB for 7 hrs

�� EMS report EMS report

�� Pt recently prescribed new antiPt recently prescribed new anti--hypertensivehypertensive

�� Pt had generalized itching rashPt had generalized itching rash

�� P 104, R 32, 220/160, Wheezing reported P 104, R 32, 220/160, Wheezing reported

�� Pt denied allergies or cardiac dsPt denied allergies or cardiac ds

�� Given 0.5mg SQ epi Given 0.5mg SQ epi

�� Pt subsequently arrested; resuscitated by EMS Pt subsequently arrested; resuscitated by EMS

with BP 220/110with BP 220/110

�� MS remained depressed with SAH on CTMS remained depressed with SAH on CT

�� Later learned had been nonLater learned had been non--compliant with compliant with

antihypertensives for monthsantihypertensives for months

�� Authors conclusionAuthors conclusion

�� EMS should not have epi on standing order anything EMS should not have epi on standing order anything

other than cardiac arrestother than cardiac arrest

Histamine AntagonistsHistamine Antagonists

�� Diphenhydramine (25mgDiphenhydramine (25mg--50mg IV or PO)50mg IV or PO)

�� HH11 blockerblocker

�� Counters effects of histaminesCounters effects of histamines

�� Few serious side effectsFew serious side effects

�� Everyone gets itEveryone gets it

ββ2 2 AgonistsAgonists

�� AlbuterolAlbuterol

�� Inhaled deliveryInhaled delivery

�� BronchodilatorBronchodilator

�� Limited cardiac effectLimited cardiac effect

�� Rapid administrationRapid administration

�� TerbutalineTerbutaline

�� SQ deliverySQ delivery

�� Similar effects and benefitsSimilar effects and benefits

IV FluidsIV Fluids

�� Vascular permeability leads to intravascular Vascular permeability leads to intravascular

depletiondepletion

�� As much as 35% of intravascular volume may As much as 35% of intravascular volume may

extravisate in the first 10 minutesextravisate in the first 10 minutes

�� Position supine with legs elevatedPosition supine with legs elevated

�� An association with death in the standing patient has An association with death in the standing patient has

actually been describedactually been described

�� May require several liters of NSMay require several liters of NS

CorticosteroidsCorticosteroids

�� Methylprenisolone IV or Prednisone POMethylprenisolone IV or Prednisone PO

�� Time to effect is similarTime to effect is similar

�� Treats bronchospasm and cutaneous symptomsTreats bronchospasm and cutaneous symptoms

�� Slow onsetSlow onset

�� Prevents biphasic reactionPrevents biphasic reaction

�� Limited effects in preLimited effects in pre--hospital periodhospital period

�� Use only after other drugs have been employed Use only after other drugs have been employed

Biphasic ReactionsBiphasic Reactions

�� Frequency in literature is 1Frequency in literature is 1--20%20%

�� More common than initially thoughtMore common than initially thought

�� Usually affects same organ systemUsually affects same organ system

�� 3 cases in literature of primary respiratory 3 cases in literature of primary respiratory

involvement who returned in profound shockinvolvement who returned in profound shock

�� Increased suspicion in respiratory involvementIncreased suspicion in respiratory involvement

�� Greater fatality rateGreater fatality rate

�� Most in 1Most in 1--72 hrs but incidence decreases 72 hrs but incidence decreases

dramatically after 4dramatically after 4--6 hrs6 hrs

Smit et al. 2005

DispositionDisposition

�� Improvement may be temporary (particularly Improvement may be temporary (particularly

with food allergies) with food allergies)

�� Patients treated for allergic reaction should be Patients treated for allergic reaction should be

encouraged to go to the hospitalencouraged to go to the hospital

�� Those who receive epi or have facial/airway Those who receive epi or have facial/airway

involvement should be observed for 4 hrsinvolvement should be observed for 4 hrs

�� Strongly encourage to go to hospitalStrongly encourage to go to hospital

�� Reoccurrence can be fatal Reoccurrence can be fatal

Diabetes and Diabetes and

HypoglycemiaHypoglycemia

Diabetes BasicsDiabetes Basics

�� Insulin dependent diabetesInsulin dependent diabetes

�� Pancreas no longer produces adequate insulinPancreas no longer produces adequate insulin

�� Treated with supplemental insulinTreated with supplemental insulin

�� BaselineBaseline

�� DemandDemand

�� NonNon--Insulin dependent diabetesInsulin dependent diabetes

�� Cells are resistant to insulin producedCells are resistant to insulin produced

�� Typically treated with oral medicationTypically treated with oral medication

�� Stimulates productionStimulates production

�� Improves response to produced insulinImproves response to produced insulin

Oral Hypoglycemic AgentsOral Hypoglycemic Agents

NIDDM patients are adjusted to a baseline on NIDDM patients are adjusted to a baseline on

their oral hypoglycemic agents sotheir oral hypoglycemic agents so………….WHY .WHY

would they become hypoglycemic?would they become hypoglycemic?

Oral Hypoglycemic AgentsOral Hypoglycemic Agents

�� Requires search for cause of hypoglycemiaRequires search for cause of hypoglycemia

�� Change in medicationChange in medication

�� Increased metabolic demand (infection)Increased metabolic demand (infection)

�� Accidental overdoseAccidental overdose

�� Long half lifeLong half life

�� Increased risk of repeat hypoglycemiaIncreased risk of repeat hypoglycemia

�� Patients should be seen in EDPatients should be seen in ED

�� May be admitted for ongoing glucoseMay be admitted for ongoing glucose

HypoglycemiaHypoglycemia

�� Brain requires glucose to functionBrain requires glucose to function

�� Hypoglycemia results in decreased functionHypoglycemia results in decreased function

�� Measured blood glucose is poorly correlated Measured blood glucose is poorly correlated with clinical picturewith clinical picture

�� Exact time of injury to the brain due to Exact time of injury to the brain due to hypoglycemia is not clear but hypoglycemia is not clear but …….it is measured .it is measured in hours not minutesin hours not minutes

�� Hypoglycemia is NOT a life threatening Hypoglycemia is NOT a life threatening emergencyemergency

Treating HypoglycemiaTreating Hypoglycemia

�� This can be a frequent event for diabeticsThis can be a frequent event for diabetics

�� Use the LEAST invasive manner of treatment Use the LEAST invasive manner of treatment

that is clinically appropriatethat is clinically appropriate

�� When possible use oral glucoseWhen possible use oral glucose

�� Use caution if patient is not alertUse caution if patient is not alert

�� If there is risk to airway use IV routeIf there is risk to airway use IV route

�� Make certain there is a patent IVMake certain there is a patent IV……if in doubt DO if in doubt DO

NOT use the IV for glucose!NOT use the IV for glucose!

Patient Refusing CarePatient Refusing Care

�� People (with capacity) have right to decide their carePeople (with capacity) have right to decide their care�� Even if that is not what we would do Even if that is not what we would do -- or or --

�� Not in their best interest Not in their best interest –– or or ––

�� Just plain stupid.Just plain stupid.

�� This is not an insult to usThis is not an insult to us…… it is simply their right.it is simply their right.

�� It does not negate our duty to try to provide the best It does not negate our duty to try to provide the best care we can.care we can.

�� NeverNever withhold a treatment just because someone is withhold a treatment just because someone is going to refuse additional care. (they can also refuse going to refuse additional care. (they can also refuse individual treatments)individual treatments)

Safety of a Treated HypoglycemicSafety of a Treated Hypoglycemic

�� Feed them!Feed them!

�� Complex sugars and proteins give sustained glucoseComplex sugars and proteins give sustained glucose

�� Leave them with someoneLeave them with someone

�� Call a neighbor, friend or family memberCall a neighbor, friend or family member

�� Call medical control or their doctorCall medical control or their doctor

�� Helps to encourage them to go to the hospitalHelps to encourage them to go to the hospital

�� Remind them that they will get low sugars againRemind them that they will get low sugars again

�� Can die if nobody there to find themCan die if nobody there to find them

�� Encourage to go to ED or call their MD (again)Encourage to go to ED or call their MD (again)

ENDEND

Philosophy of Five - Login - · PDF filePhilosophy of Five Paul R ... Objective A change in your practice Protocols and Medical Control The importance of history taking Formulating

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