Regional ACP Recertification Program

Transcription

1 Regional ACP Recertification Program

2 Overview Lead II Rhythm Interpretation Airway Management Pediatric Resuscitation Stroke Bypass Protocol Test Review Local Material

3 Lead II Rhythm Interpretation The paramedic will be able to: - list the 5 steps of ECG interpretation - differentiate between normal and prolonged PR intervals, and between normal and wide QRS complexes on ECG rhythms - define and recognize PEA - analyze (interpret) basic rhythms.

4 Rhythm Interpretation It is important to recognize basic ECG rhythms as they may determine if a patient remains on scene or is transported to the closest hospital. (e.g. PEA in a traumatic VSA) 4

5 5 Steps of Rhythm Interpretation RATE: < 60 = Bradycardia, = NORMAL, > 100 = Tachycardia RHYTHM: Regular, or Irregular: Irregularly irregular, Regularly irregular, Chaotic (VF)Artifact P-R INTERVAL: seconds P-QRS-T RELATION: is there a P wave for every QRS complex? QRS WIDTH: seconds ** Anything MISSING OR ADDED? 5

6 Normal ECG The QRS complex should be less than 0.12 seconds. This is 3 small squares (3 X 0.04 = 0.12 sec.) The PR Interval should be less than 0.20 seconds. This is 1 large square or 5 small squares. 6

7 Calculating Heart Rate Count number of QRS complexes in a 6 second strip and multiply by 10 7

8 Calculating Heart Rate 6 sec 3 sec 3 sec x 10 = 60 8

9 What s the Heart Rate? 6 seconds 40/min 9

10 What s the Heart Rate? 6 seconds 170/min 10

11 Calculating Heart Rate Method 2: Count the number of 5mm squares between each R wave and divide the number into 300. This will give you the approximate rate/minute. Method 3: Using the following scale, each number represents a 5mm square

12 12 What is the rhythm?

13 13 What is the rhythm?

14 14 What is the rhythm?

15 15 What is the rhythm?

16 16 What is the rhythm?

17 Final Rhythm The patient is VSA! 17

18 Pulseless Electrical Activity PEA can have many rhythm variations. QRS complexes in PEA can be fast or slow, narrow or wide. In cases of PEA use the pattern of the electrical activity as a clue to guide treatment. The cardiac rhythm of the patient with PEA is not the primary target of treatment: the true target is the cause of PEA. PEA refers to any semi-organized electrical activity that can be seen on the monitor screen although the patient lacks a palpable pulse. (Excludes VF, pulseless VT and asystole) 18

19 Pulseless Electrical Activity Hypovolemia Hypoxia Hydrogen ion (acidosis) Hypokalemia/hyperkalemia Hypoglycemia Hypothermia Toxins Tamponade, cardiac Tension Pneumothorax Thrombosis - pulmonary Thrombosis coronary (AMI) Trauma 19

20 Summary Determine rate, rhythm, PR interval, P-QRS-T relationship, and QRS width to help you identify the rhythm A normal PR interval is less than 0.2 seconds long (5 small boxes) A normal QRS complex is less than 0.12 seconds wide (3 small boxes) The four critical rhythms every paramedic should know are: Normal Sinus Rhythm Pulseless V-Tach V-Fib Pulseless Electrical Activity 20

21 References Advanced Care Paramedic Medical Directives Blunt and Penetrating Traumatic Arrest protocols Variety ECG interpretation books and many other web-sites 21

22 22

23 Airway Mgmt Review The paramedic will be able to: - list the critical findings and presenting problems that meet the Oxygen Therapy Standard for high concentration oxygen - summarize the oxygen therapy standards for patients with COPD - express the indications and contraindications for use of an SGA - identify the key components, and demonstrate proper insertion of the King LT airway - explain the ACP standards for SGA insertion and/or leaving an existing SGA in place

24 Airway Management Oxygen Administration SGA - King LT Technique Confirmation ACP Standards for SGA Insertion 24

25 Oxygen Administration Oxygen Therapy Standard - High concentration O2 will be administered to all patients presenting with the following critical findings or presenting problems: Abdominal/back pain Allergic reaction Chest pain- any cause Electrocution Inhalation of toxic gases Major/multiple trauma Near-drowning Overdose confirmed/suspected Vision loss partial/complete Altered mental status Apnea Cyanosis Atypical pallor/ashen colour Loss of consciousness Decreased level of consciousness Respiratory distress Shock or impending shock i.e. BP<90 systolic (adult) 25

26 Oxygen Administration Pregnancy related conditions that require high concentration oxygen: ante & post partum hemorrhage All blunt trauma to the truncal area (based Hx M of Injury) Normal labour (at term) with a critical finding Premature labour Multiple births Limb presentation Umbilical cord prolapse Fetal distress i.e meconium passed through vagina pre delivery Abdominal pain Pre-eclampsia, eclampsia (obvious or suspected) Fetal HR sustained<120 or >160 26

27 Oxygen Administration Environmental related disorders that require high concentration oxygen: Scuba diving related complaints or conditions Venomous snake bites If in doubt regarding the patients oxygenation status administer high concentration oxygen!!!!!! High concentration oxygen should also be administered for brief periods (30 seconds) post suctioning and pre and post airway procedures i.e. intubation or King LTSD insertion. 27

28 Oxygen Administration C.O.P.D patients that require high concentration oxygen: Decreased level of consciousness Altered mental status Severe respiratory distress Major or multiple trauma If the C.O.P.D. patient is: Alert/anxious and mild/moderate distress can speak with minimal difficulty not cyanosed or slightly more than usual smoker >50 years old Then administer 24-28% oxygen with a nasal cannula or oxygen levels 1-2 litres per minute above home oxygen levels. 28

29 Oxygen Administration With COPD patients, watch for improvement or deterioration of respiratory distress, mental status and colour. Reassess every 5-10 minutes. If the patient feels better maintain oxygen at that level. If patient condition worsens administer high concentration oxygen ** Be prepared to ventilate. ** If in doubt as to the patient s severity or cause of the patient s respiratory distress administer high concentration oxygen. 29

30 Where are we? Oxygen Administration SGA - King LTSD Technique Confirmation ACP Standards for SGA Insertion 30

31 Supraglottic Airway Training Module 31 OBHG Education Subcommittee 2007

32 What is a King LT? Supraglottic airway with two cuffs Seals the orophyarnx and blocks off the esophagus Quick insertion requiring no laryngoscopy Reduces dead space for ventilation Helps protect from aspiration 32

33 33 King LT-D Design

34 34 King LT-D Design

35 King LT (vs. BVM) Improved ventilation (Tidal Volume) One-handed ventilation More secure airway Better seal / No loss of seal Less gastric insufflation 35

36 King LT (vs. ETT) Advantages Rapid, blind insertion Less traumatic Faster time to ventilation Shorter learning curve for technique Disadvantages Not a definitive airway 36

37 A Primary or Rescue Airway? Both! Used as: Airway management after BVM started Intermediate airway before intubation (rare case) Primary for a predicted difficult intubation Primary if limited access to pt / difficult pt positioning A back-up for a failed intubation 37

38 38 King LT in Place

39 Auxiliary SGA Protocol Indications: 1. A patient who is in cardiac arrest (PCP/ACP), or 2. GCS = 3 without a gag reflex (ACP only). Contraindications: 1. Active vomiting 2. Inability to clear airway 3. Airway edema 4. Stridor 5. Caustic ingestion 6. Complete airway obstruction ** Maximum of 2 attempts. 39

40 40 Sizing and Information

41 41 Insertion Guide: Step 1

42 42 Insertion Guide: Step 2

43 43 Insertion Guide: Step 3

44 44 Insertion Guide: Step 4

45 45 Insertion Guide: Step 5

46 Trouble Shooting If patient is difficult to ventilate or won t ventilate, the Laryngeal Tube may be placed too far in. Pull back approximately 1 2 cm and reattempt ventilation Ensure Laryngeal cuffs are properly inflated 46

47 Number of Attempts Max 2 attempts If 2 nd attempt fails revert to BVM & pharyngeal a/w ACPs may proceed to ETT 47

48 An ideal airway device Efficient bypass of upper airway Easy insertion by beginners, steep learning curve Efficacy not extremely affected by suboptimal placement Good accept-reject profile Stable in use Minimal or no aspiration risk Effective upper airway seal allowing for positive pressure ventilation 48

49 Comparison of SGA Devices LMA King LT 49

50 Comparison of SGA Devices LMA Quick establishment of the airway Effective ventilation Better ventilation than OPA / NPA Does not protect from aspiration King LT Rapid establishment of the airway Effective ventilation Better Ventilation than OPA / NPA Protects from aspiration Easy to use and train Can be used to facilitate intubation 50

51 Where are we? Oxygen Administration SGA - King LTSD Technique Confirmation ACP Standards for SGA Insertion 51

52 Airway Management ACP Standards for SGA insertion/in place ACP s will use an SGA for a back-up rescue airway after 2 failed intubation attempts and For patients with a GCS of 3 with no intact gag reflex that do not require an endotracheal tube. If an SGA is already in place and ventilation is adequate and the ACP is able to establish an IV/IO to administer medications, then leave SGA in place. If unable to establish an IV/IO then the ACP will remove the SGA and attempt ETT intubation for the purposes of medication administration. 52

53 Summary Paramedics will administer high concentration oxygen to all patients presenting with one or more of the critical findings and/or presenting problems listed in the Oxygen Therapy Standard of the BLS Standards Patients with COPD may require high-concentration oxygen, or may receive O2 by nasal cannula if in doubt, use NRB The King LT supraglottic airway is a single lumen tube with two inflatable cuffs used to control the airway in VSA patients (PCP/ACP), or patients with GCS of 3 without gag reflex (ACP only). ACPs may use the King LT as a rescue airway where intubation is not possible, or as a primary airway if intubation is not required. ACPs will leave an existing King LT in place if an IV/IO is available for medication, or may replace with ETT if medication administration by tube is required. 53

54 References Basic Life Support Patient Care Standards, January 2007, Version 2.0, Section 1, General Standard of Care. Pgs 1-48 to King LT Training Package MAC Auxiliary Supraglottic Airway Protocol Auxiliary Medical Directives, SWORBHP

55 55

56 Pediatric Resuscitation The paramedic will be able to: - state the Basic Life Support procedures for pediatric patients - explain the protocol for early transport of pediatric (<16 years) patients in nonshockable rhythms - demonstrate proper defibrillation of both adult and pediatric patients according to protocol, including unique situations such as hypothermia and obstructed airway

57 Pediatric Cardiac Arrest Usually secondary to hypoxia 57

58 Most Important Intervention Adequate Oxygenation Ventilation Often the key to preventing Pediatric Cardiac Arrest is to ensure they are properly ventilated 58

59 Basic Life Support Airway Head tilt/chin lift method Big tongue; forward jaw displacement critical Avoid extreme hyperextension with possible neck injury, jaw thrust 59

60 Basic Life Support Breathing Look-Listen-Feel Children are under ventilated! Ensure proper rate of ventilation for age of child Limit the volume to only that which causes chest rise Use only a BVM! 60

61 Basic Life Support Breathing Do not use demand valve on children Ventilate infants, children every 3 seconds 61

62 Best Sign of Effective Ventilation Chest Rise 62

63 Oxygen Therapy Initiate ASAP Do not delay Use 100% oxygen No risk in short term use 63

64 Basic Life Support Circulation (pulse check) Neonate: Umbilical stump/apical Infants: brachial Children: carotid 64

65 Basic Life Support Compressions start: Neonate HR < 60 after O2/BVM for 30 sec Infant HR < 60 and poor perfusion OR no pulse Child HR < 60 & poor perfusion OR no pulse Adult no pulse 65

66 Basic Life Support Circulation (Neonate chest compressions) Thumbs with chest encircled 1/3 depth of chest; lower 1/3 of sternum Ratio 3:1 At least 120/minute 66

67 Basic Life Support Circulation (Infant chest compressions) 2 fingers 1 finger width below the nipple line 1/2 1 inches deep At least 100/minute 67

68 Basic Life Support Circulation (Child Compressions) Maintain continuous head tilt with hand on forehead Perform chin lift (if possible) with other hand while ventilating One hand/heel of hand 1/3-1/2 depth of chest; at nipple line At least 100/minute 68

69 Best Sign of Effective Circulation Pulse with Each Compression 69

70 Defibrillation 90% of pediatric cardiac arrest are Asystole (or) Bradycardia (or) PEA Defibrillation is seldom needed! 70

71 Defibrillation Pediatric VF suggests Electrolyte imbalance Drug toxicity Electrical injury Congenital Heart Defect 71

72 Defibrillation Pad Positions 72

73 Defibrillation IMPORTANT NOTE: Please note that Adult Defibrillation Pads may be used on pediatric patients as long as the pads do not come in contact with each other when placed on the patient. Please check the manufacturers recommendations for pad size on the packaging as some pads do not fit every size and weight of pediatric patient. 73

74 Medical Directives for Pediatric Defibrillation (March 2009) Cardiac Arrest General Protocol (Non-Traumatic) Adult & Pediatric 1. Manual defibrillation applies to patients 30 days. 2. AED applies to patients 1 year old. 3. In patients 1 and < 8 years old reduced energy level options are: (A) AED with automated pediatric rhythm analysis and energy attenuation through attenuation cables or, (B) manual energy selection defibrillation. Where one of these methods is available, it must be used. or (C) If reduced energy capability is not available, a paramedic will use adult pads and adult energy settings. 74

75 Use of Manual Energy Selection (B) Manual energy selection defibrillation. Manual defibrillation applies to patients 30 days. 75

76 Use of Manual Energy Selection Defibrillation Procedure To defibrillate the patient: 1. Press ON to turn on the defibrillator. 2. Apply the therapy electrodes to patient in anteriorlateral or anterior-posterior position. 3. Confirm V-Fib or Pulseless V-Tach 4. Select the appropriate energy (2 J/Kg) by pressing ENERGY SELECT or dial ENERGY SELECT for the weight of the child according to the protocol. 5. Press CHARGE. 6. Make certain all personnel are clear of the patient, the bed, and any equipment connected to the patient. 76

77 Use of Manual Energy Selection Defibrillation Procedure (cont d) 7. Confirm ECG Rhythm. Confirm available energy. 8. Press the SHOCK button to discharge energy to the patient. 9. To remove an unwanted charge, press the selector knob (LP), or wait for auto-dump (ZOLL). 10. Continue with defib protocol. For subsequent shocks, set energy level at 4 J/Kg. 77

78 Use of Manual Energy Selection Energy settings: Initial: 2 J/kg Repeat: 4 J/kg 78

79 Use of Manual Energy Selection IMPORTANT NOTE: Energy capabilities vary from defibrillator to defibrillator, therefore, the exact energy selection required may not be present which will require the operator to round to the closest energy selection. Please become familiar and comfortable with the equipment provided to you. 79

80 Joule Calculation Age Weight Exact Joule Available (kg) 2j/kg & 4j/kg Joule 2j/kg& 4j/kg Weight = (age) X Therefore: 2y/o weight = (2) x 2+10=14kg Total joules for 2 year old: 14kg x 2J =28J (1 st shock) 14kg x 4J =56J (subsequent shocks if initial is not successful) 30 d 1 yr calculate /48 20/ /56 30/ /64 30/ /72 30/ /80 50/ /88 50/ /96 50/100 80

81 Manual Defib LifePak Manual Defib Zoll 81

82 Medical Directives for Pediatric Defibrillation (March 2009) Cardiac Arrest General Protocol (Non-Traumatic) Adult & Pediatric Notes, Point 3 states: 3. Transport of the Cardiac Arrest Patient: initiate transport in the following circumstances: 82

83 Medical Directives for Pediatric Defibrillation (March 2009) a. PCP Analyze has been pressed four times (generally 3 times on scene and 1 time in the ambulance) and the appropriate response has been taken. This includes actions taken by onscene AED equipped first responders. Note: Stop CPR and check for a pulse enroute if the patient develops obvious signs of life. OR b. PCP/ACP In unusual circumstances such as pediatric patients < 16 years old, paramedics may consider early transport after the first no shock message or first non- VF/VT manual rhythm analysis. 83

84 Medical Directives for Pediatric Defibrillation (March 2009) OR c. PCP/ACP You have detected a ROSC OR d. PCP/ACP You have been directed to transport by the Base Hospital Physician. 84

85 Medical Directives for Pediatric Defibrillation (March 2009) Defibrillation Notes: Paramedic may transport after 1 unshockable rhythm, and will transport after 4 shocks have been delivered (age < 16 years). Remember, preferred method is do not stay on scene when resuscitating a pediatric patient in a non-shockable rhythm. Load and go after you interpret any rhythm that will not potentially respond to defibrillation. 85

86 Medical Directives for Pediatric Defibrillation (March 2009) Defibrillation Notes: After ROSC on scene, if the patient re-arrests enroute, bring the ambulance to a complete stop, analyze the rhythm and treat accordingly. Shockable Rhythm Defibrillate, resume CPR and transport with no further stops. Non-shockable rhythm Check pulse, if no pulse resume CPR and transport with no further stops. 86

87 Foreign Body Airway Obstruction Cardiac Arrest Protocol (Adult & Pediatric) When a patient is found to be in cardiac arrest (VSA) and it is apparent that the patient has an obvious foreign body airway obstruction, the paramedic will treat according to the following protocol. Indications Patient who is in cardiac arrest with an apparent foreign body airway obstruction. 87

88 Foreign Body Airway Obstruction Cardiac Arrest Protocol (Adult & Pediatric) Procedure 1. Confirm patient is VSA while partner assembles airway equipment. 2. Begin chest compressions. 3. Attempt to ventilate the patient when airway equipment is assembled. 4. If air entry does not occur, re-adjust the airway and reattempt ventilation. 88

89 Foreign Body Airway Obstruction Cardiac Arrest Protocol (Adult & Pediatric) 5. If the second ventilation does not enter the lungs, the patient is deemed to have an obstructed airway. PCP: Visualize inside the patient s mouth after every set of chest compressions and remove the obstruction if visualized. ACP: Visualize inside the patient s upper airway using a laryngoscope and Magill forceps. Remove foreign body if visualized. 89

90 Foreign Body Airway Obstruction Cardiac Arrest Protocol (Adult & Pediatric) 6. Start the medical Cardiac Arrest General Protocol performing one analysis or manual rhythm check. 7. IV access should not be attempted until the airway obstruction is cleared. 8. If the foreign body airway obstruction cannot be cleared: PCP: Initiate rapid transport after 2 minutes of attempting to clear the obstruction and responding to the first analysis. ACP: Follow the Auxiliary Emergency Cricothyrotomy Protocol (if certified) after 2 failed attempts to remove the obstruction using Magill forceps. Initiate rapid transport. 9. If the obstruction is cleared, start the Cardiac Arrest General Protocol from the beginning, count any shocks/analyses that have been completed. 90

91 Hypothermic Cardiac Arrest General Protocol Adult & Pediatric When a patient is found to be in cardiac arrest (VSA) and convincing evidence exists that the patient is severely hypothermic, the paramedic will treat the patient according to the following protocol. Indications Patient who is in cardiac arrest (VSA) with severe hypothermia. Severe hypothermia suspected by: a. History indicating that the patient has suffered prolonged exposure to a cold environment. b. Central body temperature is cold to the touch (chest, abdomen, and under arms) c. Skin appears to be white/waxy in nature. d. May have stiff limbs. 91

92 Hypothermic Cardiac Arrest General Protocol Adult & Pediatric Procedure 1. Confirm cardiac arrest by the absence of spontaneous respiration and palpable central pulses. A 45-second pulse check should be performed. 2. Initiate chest compressions and ventilations for approximately 2 minutes. 3. Attach defibrillator while performing CPR. 4. Initiate therapy according to the PCP or ACP Cardiac Arrest General Protocol. Continue until the first Analysis or Manual rhythm check has been performed and CPR has been re-initiated if necessary. 5. Transport should be initiated quickly. No further defibrillation efforts enroute. Update receiving facility enroute. 6. Establish IV access enroute (if certified). No IV drugs will be administered. 92

93 Reminders to avoid Potential Pitfalls 1. Check Defib Pad sizing verify on packaging maximum and minimum weight requirement per patient 1. Translates to how much energy the Defib Pads can safely deliver. 2. Verify Defib Pad expiration date 3. Double check Math for Manual Defib 1. 2 J/kg followed by 4J/kg 4. Verify proper Pad placement 1. Anterior/Lateral or Anterior/Posterior 2. Confirm the pads are NOT touching 93

94 Summary Provide Basic Life Support in accord with current OHSF standards Pediatric arrest is usually secondary to respiratory arrest or failure control airway, oxygenate, and ventilate well Patients under the age of 16 years will be transported after 4 shocks, or after the FIRST non-shockable rhythm analysis (preferred method) Hypothermic cardiac arrest patients require a 45-second pulse check initially 94

95 References OHSF Basic Life Support Guidelines PCP Medical Directives SWORBHP General Traumatic Arrest Protocol Adult & Ped PCP Blunt Traumatic Arrest Adult & Ped PCP Penetrating Traumatic Arrest Adult & Ped Cardiac Arrest General Protocol Adult & Ped Neonatal Resuscitation Protocol 95

96 96 Time to Check in!

97 Stroke Bypass Review The paramedic will be able to: - describe the indications and contraindications for stroke bypass protocol - list the available stroke centres in the region.

98 Indications for Patient Transport to a Designated Stoke Centre A patient who has a new onset of at least one of the following symptoms suggestive of the onset of an acute stoke Unilateral arm/leg weakness or drift Slurred or inappropriate words or mute Facial Droop AND Can be transported to arrive within two (2) hours of a clearly determined time of symptom onset or the time the patient was last seen in a usual state of health 98

99 Contraindications for Patient Transport to a Designated Stroke Centre Any of the following conditions exclude a patient from being transported under Stoke Protocol CTAS Level 1 and/or uncorrected Airway, Breathing or Circulatory problem Symptoms of the stroke have resolved Blood Sugar 4 mmol/l Seizure at onset of symptoms or observed by paramedic Glasgow Coma Scale <10 Terminally Ill or Palliative Care Patient 99

100 Transport Guidelines One a patient has been assessed as meeting the Stroke Protocol the paramedic will notify CACC of the need for transport to a Stroke Centre CACC will confirm availability of a Stroke Centre CACC will then authorize the bypass of the closest hospital if a Stroke Centre is available 100

101 Stroke Centres Grey Bruce District Stroke Centre Grey County, Bruce County Grey Bruce Health Services - Owen Sound Site, Owen Sound Huron Perth District Stroke Centre Huron County, Perth County Stratford General Hospital, Stratford Thames Valley District Stoke Centre Middlesex County, Oxford County, Elgin County London Health Sciences Centre University Hospital Site, London 101

102 Stroke Centres Sarnia Lambton District Stroke Centre Lambton County Bluewater Health Mitton Site, Sarnia Chatham Kent District Stroke Centre Chatham - Kent Chatham - Kent Health Alliance Chatham Hospital, Chatham Windsor Essex District Stroke Centre Windsor, Essex County Hotel Dieu Grace Hospital, Windsor 102

103 References Stroke Strategy Southwestern Ontario (2008). Regions and Districts. Retrieved August 7, 2009, from Ministry of Health and Long Term Care. Paramedic Prompt Card for Acute Stroke Protocol. Version 1.0. March Ministry of Health and Long Term Care. Basic Life Support Patient Care Standards. January Version 2.0. Section 2 Pages

104 104

105 105 BREAK TIME!

106 Manual Pediatric Defibrillation Buttonology for the LifePak 12 To be able to employ the LP12 in Manual mode for pediatric defibrillation.

107 107 Lifepak 12 Orientation

108 Lifepak 12 Orientation Area 1 is the primary focus 108

109 LP12 Buttonology Area 1-Shock Delivery Section Area 1-Shock Delivery Section Steps: 1. Push On Button 2. Analyze Button (to view Paddles View) 3. Decrease Joules by pressing Energy Select Converting to Manual Mode 4. Energy Select to adjust to the appropriate Joule setting 2J/Kg or 4J/Kg. 109

110 Converting to Manual Mode 1. Push ON Button 2. Push Analyze Button 3. Push Advisory Button 4. rotate Selector Knob to choose options 5. Push Selector Knob in to enter options 110

111 Converting to Manual Mode (after pushing energy select) 111

112 112 Click Button to Return to presentation

113 Manual Pediatric Defibrillation Buttonology for the Zoll E &M series To be able to employ the Zoll Defib in Manual mode for pediatric defibrillation.

114 114 Zoll E and M series Orientation

115 Zoll E and M series Orientation 1. Turn Selector Knob to Select DEFIB 2. Chose appropriate Joule setting by pushing Energy Select arrows 3. Push Charge Button 4. Push Shock Button 115

116 116 Click Button to Return to presentation