EMS Subspecialty Certification Review Course. Learning Objectives Cricothyrotomy

Transcription

1 EMS Subspecialty Certification Review Course Cricothyroidotomy Control of Post Tonsillectomy Hemorrhage 1.4 Special Considerations Version Date: February 2013 Learning Objectives Upon the completion of this program participants will be able to: Describe application of needle and surgical cricothyrotomy in EMS List EMS priorities in post tonsillectomy hemorrhage Cricothyrotomy EMS Scope of Practice for Paramedic: Percutaneous (needle) cricothyrotomy Needle only Kits: Seldinger tech to place cuffed / uncuffed tube Surgical Cricothyrotomy Not in minimum National Scope High criticality / low frequency skill Application: failed airway, severe facial trauma Competency attainment and maintenance issues 3 1

2 Control of Post Tonsillectomy Hemorrhage % rate Most common POD 5 7 External carotid artery system Surgical hemostasis required (ENT) Management: No clot removal Maintain airway Mandates transport and ED evaluation regardless if ongoing bleeding 4 Take Home Points These topics are part of the EMS core content (Clinical Aspects of EMS Medicine, 40%) Needle cric is within the Paramedic minimum scope, surgical is not. Airway skills scope varies by state and local protocol Post tonsillectomy hemorrhage mandates transport regardless 5 EMS Subspecialty Certification Review Course Trauma Needle thoracostomy Tube thoracostomy Pericardiocentesis without U/S guidance Control of life threatening hemorrhage Application of traction devices Wound care management Version Date: July

3 Learning Objectives Upon the completion of this program participants will be able to: Describe indications for and unique aspects of the following procedures in EMS: Needle thoracostomy Tube thoracostomy Pericardiocentesis (ECG assisted) without ultrasound guidance Application of traction devices List EMS specific issues in wound care management Describe current methods for control of life threatening hemorrhage in the EMS environment 7 Questions What are the indications for prehospital needle thoracostomy? What findings suggest cardiac tamponade? What type of fracture can a traction splint be considered for? Prompt surgery is indicated for greater than?? cc/hr chest tube output Needle thoracostomy EMS Indications: Trauma PEA arrest Trauma in extremis, unexplained hypotension COPD patient with rapid deterioration Technique: Anterior vs. Lateral approach Potential need to repeat Equipment: Needle of adequate length to reach pleural cavity One way valve 9 3

4 Tube thoracostomy Indications: Respiratory compromise due to pneumothorax PPV Potential for expansion of pneumothorax due to nonpressurized flight Procedure same as in hospital, lateral approach As in hospital, > 1000 cc immediately after chest tube or > 300 cc/hr means surgery Pericardiocentesis without ultrasound guidance Not within the minimum EMS Scope of Practice Limit to physician intervention Indication: Relief of tamponade Last resort: potentially lifesaving in critical cardiac tamponade Beck s triad Pulsus paradoxus PEA arrest PEA unresponsive to fluid bolus (+ pressors) and needle decompression Pericardiocentesis without ultrasound guidance Subxiphoid approach: Needle to left of xyphoid Puncture skin Attach precordial ECG lead and aspirating syringe Advance needle, aim for left shoulder at shallow angle Ultrasound increases safety ECG assisted if ultrasound not available: when needle contacts epicardium, current of injury wide PVC or ST elevation is seen Stop advancing when pericardial fluid is aspirated Leave catheter in, place stopcock Video 12 4

5 Control of life threatening hemorrhage Internal: Pelvic splinting Femur splinting Tranexamic Acid 13 Control of life threatening hemorrhage External Direct pressure Pressure points Tourniquets Hemostatic agents PASG: pneumatic antishock garment 14 Application of traction devices Goals: limit pain, further vascular / neuro injury Indications: Femur fracture without unstable pelvic fracture Contraindications: Open fracture with gross contamination or sciatic nerve injury Types: Hare Sager 15 5

6 Wound care management Limit additional contamination with sterile dressing Evaluate distal pulse, sensation, and motor function 16 Take Home Points This topic is part of the EMS core content: Clinical Aspects of EMS Medicine (40%) Pericardiocentesis is indicated for nonhemorrhagic tamponade refractory to fluids and pressors Traction devices are indicated for closed femur fractures 17 Take Home Points Describe indications for and unique aspects of the following procedures in EMS: Needle thoracostomy Tube thoracostomy Pericardiocentesis (ECG assisted) without ultrasound guidance Application of traction devices List EMS specific issues in wound care management Describe current methods for control of life threatening hemorrhage in the EMS environment 18 6

7 EMS Subspecialty Certification Review Course Pericardiocentesis without U/S guidance Balloon pump management Version Date: July 2013 Learning Objectives Upon the completion of this program participants will be able to: Describe indications for pericardiocentesis Describe specific technique for ECG assisted pericardiocentesis List indications and pathophysiology of IABP Describe specific critical maintenance aspects and complications of IABP maintenance in transit Pericardiocentesis without ultrasound guidance Not within the minimum EMS Scope of Practice Limit to physician intervention Indication: Relief of tamponade Last resort: potentially lifesaving in critical cardiac tamponade Beck s triad Pulsus paradoxus PEA arrest PEA unresponsive to fluid bolus (+ pressors) and needle decompression Strongly recommend ultrasound capability as adjunct in current EMS environment 21 7

8 Pericardiocentesis without ultrasound guidance Equipment Antiseptic Local anesthetic Syringes (10, 20+) Extension tubing Stopcock 18ga spinal needle x 3.5 inch Pericardiocentesis without ultrasound guidance Subxiphoid approach: Needle to left of xyphoid Puncture skin Attach precordial ECG lead (V1) and aspirating syringe Advance needle under continuous aspiration, aim for left shoulder at shallow angle Ultrasound increases safety ECG assisted if ultrasound not available: when needle contacts epicardium, current of injury wide PVC or ST elevation is seen Stop advancing when pericardial fluid is aspirated ACCF/AHA Recommendations 8. Complications After STEMI: Recommendations 8.1. Treatment of Cardiogenic Shock CLASS IIa: The use of intra aortic balloon pump counterpulsation can be useful for patients with cardiogenic shock after STEMI who do not quickly stabilize with pharmacological therapy (Level of Evidence: B) 24 O Gara ACCF/AHA STEMI Guideline Executive Summary. JACC 61(4):

9 Intra aortic balloon pump management Used as a pre or post PCI bridge therapy, in high risk patients peri cardiopulmonary bypass Indication: severe left ventricular dysfunction and cardiogenic shock, refractory to volume resuscitation and pressors Contraindication: aortic insufficiency, aortic dissection Mechanism: preload, augmented CO (30% mean ) Femoral insertion of catheter with balloon into aorta Complications: limb ischemia, access site hemorrhage, cardiac tamponade, malpositioning (cerebral, renal ischemia), aortic dissection Decreases mortality Intra aortic balloon pump management Initial setting of 1:1 (1 heart contraction = 1 balloon inflation). Correct timing of balloon inflation to cardiac cycle is crucial to proper function, otherwise precipitates hemodynamic instability If patient decompensates, know your IABP recommendations for troubleshooting and ability to defibrillate with IABP in operation. Common problems and complications include: Balloon rupture Incorrect timing of balloon inflation in cardiac cycle Clot formation with IABP in standby Limb ischemia and aortic dissection In transit, assure: Adequate power in battery Adequate gas (helium) in tank 26 Take Home Points This topic is part of the EMS core content: Clinical Aspects of EMS Medicine (40%) Pericardiocentesis is indicated for nonhemorrhagic tamponade refractory to fluids and pressors IABP increases cardiac output and coronary perfusion IABP requires power, helium, and proper timing to ECG cycle to maintain hemodynamics Complications of IABP in transit include balloon malposition, improper timing, limb ischemia, aortic dissection 27 9

10 EMS Subspecialty Certification Review Course POC Testing Version Date: July 2013 Learning Objectives In general, POC testing shifts focus from treating presumptively to ability to demonstrate need and focus management based on data. Upon the completion of this program participants will be able to: List several POC tests that are or could be used in the EMS environment List the three major goals of POC tests in EMS 29 Potential POC tests for EMS Glucose Cardiac enzymes Electrolytes Hemoglobin Carboxyhemoglobin Lactate Stroke related tests: Glutamate? Beta natriuretic peptide (BNP) 30 10

11 POC testing in EMS Goal is to provide information that alters or dictates: specific management, patient destination. or shortens time course to definitive management Logistics: Cost of cartridges / test strips Quality control / CLIA requirements Cost of analysis machines and ability to use (and survive) in transport environment 31 Take Home Points This topic is part of the Clinical Aspects of EMS Medicine (40%) Incorporation of POC testing provides potential for greater specificity in EMS management in many areas. As more POC testing capacity is developed, EMS medical directors should maintain awareness of which specific tests may be applicable and costeffective in their system. 32 EMS Subspecialty Certification Review Course Ultrasound use in EMS FAST Examination Line placement Cardiac activity for field TOR Version Date: July

12 Learning Objectives Upon the completion of this program participants will be able to: List at least 3 ways that ultrasound can be applied in the EMS environment and how it changes patient care FAST Examination Focused Assessment with Sonography for Trauma 4 views: Cardiac: r/o pericardial effusion evaluate cardiac activity RUQ (liver / kidney) Morison s pouch LUQ (spleen / kidney) Pelvic + extended FAST: lung evaluation for pneumothorax Early identification of patients with who require early surgical or procedural intervention Line placement Anatomic vs. ultrasound guidance Central vs. peripheral venous access Central: subclavian, internal jugular, femoral Peripheral: cephalic, basilic Static vs. dynamic ultrasound use Allows improved accuracy and potentially decreased complications in line placement 36 12

13 Cardiac activity for field TOR PEA arrest conundrum: Mechanical activity with profound hypotension? Pericardial tamponade? Tension pneumothorax? Vs. Electrical activity only? Allows definitive determination of death 37 Potential Future Applications of Ultrasound in EMS Pneumothorax evaluation Airway placement Volume status assessment 38 Take Home Points This topic is part of the EMS Clinical Aspects of EMS Medicine (40%) Ultrasound has potential for numerous EMS applications that can improve and expedite patient care 39 13

14 EMS Subspecialty Certification Review Course Implantable cardiac devices & Use of magnets for management of devices Version Date: Learning Objectives Upon the completion of this program participants will be able to: Describe different types of implantable cardiac devices and conditions where used Identify common complications/problems with implanted devices Describe the effect of applying a magnet to different devices 41 Implanted Devices Pacemakers and AICD placed for: Rate related pathology Sudden death Severe heart failure Non ischemic/ischemic cardiomyopathy Pacemakers may be Asynchronous fixed rate (rare) Demand triggered 42 14

15 Pacemaker Problems Mechanical (pocket, leads*) Operational Failure to sense/pace Inappropriate or runaway pacing Inappropriate pacing may trigger tachydysrhythmia Battery: end of life issues 43 AICD Problems Operational failure Sensing/triggering failure Inappropriate cardioversion* Ineffective cardioversion Device deactivation 44 Magnet Magnet applied to pacer activates intrinsic fixed rate Does NOT turn off device Magnet applied to AICD turns off device End of life care Resuscitation Inappropriate shocks Use by EMS providers is unclear 45 15

16 Take Home Points Clinical aspects of EMS = 40% of tests items Take home points Implanted devices commonly used for rate/ventricular pathology Problems with AICD & pacemaker are similar and commonly related to lead failure or inappropriate triggering Magnets may be used to activate intrinsic rate in pacemakers and deactivate AICDs 46 16