Chapter 18. Learning Objectives. Learning Objectives 9/11/2012. Critical Care Transport. Define following transport equipment:

Transcription

1 Chapter 18 Critical Care Transport Learning Objectives Define following transport equipment: IV lines Flow controllers Pressure bags Infusion sets IV pumps Drug calculators Fluid warmers Learning Objectives Discuss medications used in transport for treatment of HELLP syndrome: Dexamethasone (Decadron) Magnesium sulfate Phenytoin (Dilantin) Hydralazine (Apresoline) Labetalol (Trandate, Normodyne) 1

2 Learning Objectives Discuss medications used in transport for treatment after cardiac arrest or myocardial infarction: Vecuronium (Norcuron) Amiodarone (Cordarone) Midazolam (Versed) Eptifibatide (Integrilin) Learning Objectives Discuss medications used in transport for treatment of closed-head injury: Propofol (Diprivan) Fentanyl citrate (Sublimaze) Mannitol (Osmitrol) Learning Objectives Describe Parkland formula, Wallace rule of nines, and rule of palms in treating patients with burn injury List signs and symptoms of blood transfusion reaction 2

3 Introduction Can include air medical transport from scene Ground and air transport from one facility to another Introduction Interfacility transport Involves different patient management strategies Multiple medications Advanced procedures IV lines Peripheral line 14- to 24-gauge catheter inserted into peripheral vein Central venous catheter IV catheter inserted into central vein to allow quick administration of medications and large volumes of fluid 3

4 IV lines Triple-lumen catheter (TLC) Has 3 ports that are color coded: distal, medial, proximal Ends of catheters must be read to determine placement Distal port: at end of catheter Medial port: between distal and proximal ports Proximal port: at end of catheter closest to exit from patient IV lines Peripherally inserted central catheters (PICC) lines Entry point is upper extremity End of catheter is in central vein Must be regularly flushed to prevent clotting Some are implantable in patients that require frequent IV medications 4

5 IV lines Huber needle is used to access ports IV lines Arterial line Invasive line used for continuous BP monitoring Pressurized tubing Transducer Bag of normal saline inside pressure bag If you transport patient with arterial line but your monitor does not have capability to monitor invasive BP, prepare patient with attached pressure bag Used only for monitoring Do not administer any medications or fluids into these lines 5

6 Flow controllers Sometimes used during critical care transport Most common: Dial-A-Flo Can be connected to IV tubing as extension set Allows paramedic to adjust dial and deliver a set volume of fluid Pressure bags By inflating pressure bag over IV fluids, paramedic can increase amount of volume delivered to patient Used to increase rate of IV administration When high IV flow rates are required Can accommodate either 500-mL or 1000-mL bags of fluid 6

7 Pressure bags Setup: Slot for placement of IV fluid Connector from bag to balloon pump Valve regulator Attached stopcock Pressure bags Once bag is inflated to 300 mm Hg, green regulator valve appears If overinflated, red valve appears Stopcock must be turned upward to maintain pressure in the bag When bag is ready for deflation, turn downward 7

8 Infusion sets Used in administration of IV fluids through peripheral or central venous catheters Macrodrip sets Allow administration of 1 ml of fluid in 10 to 15 drops, depending on set Used to administer rapid infusions and basic fluids Infusion sets Microdrip sets Can administer 1 ml of fluid in 60 drops Makes drug calculations easier without use of pump Blood tubing sets Usually found as Y-type blood sets Deliver 10 drops/ml with integrated blood filter Allows administration of infusion of both normal saline and blood at same time 8

9 Infusion sets Volume-control chamber sets Used to prevent fluid overloading in patients Must first fill with desired amount of fluid Set clamp between IV fluid and volume-control chamber for remainder of administration Clamp between volume-control chamber and patient can be opened for safe administration of fluids or medications IV infusions can be injected in volume-control chamber and diluted with IV fluids administered over specific period Infusion sets Vented Necessary for administration of fluids packaged in glass containers Nitroglycerin Eptifibatide (Integrilin) Propofol (Diprivan) Albumin Have side port at drip chamber that can be opened to allow air flow into closed fluid container 9

10 Infusion sets Nonvented Do not have port for air flow into closed fluid container Used for fluids not packaged in glass containers Crystalloid solutions Infusion sets Multidrip sets SELEC-3 system allows paramedic alternate among a 10-, 15-, and 60-drop set on one system Quick, easy, cost-effective way to make changes to infusion without changing drip sets 10

11 IV pumps 3-channel pump Allows administration of 3 separate drugs Lightweight devices are easier to transport Equipped with technology that integrates drug calculator into system IV pumps MiniMed system Used with 3-channel pump Can be used with two types of infusion sets Whole set Half set 11

12 IV pumps Syringe system Decreases bulk when transporting patient Uses large syringe containing medication Entire syringe is placed in pump calibrated to compress plunger of syringe slowly Delivers medication at desired infusion rate Decreases risk involved with transporting on multiple drips supplied in glass bottles Using syringe with a half-set, note time of transport IV pumps Syringe system Most systems provide on-screen, step-by-step instructions to resolve problems Infusion pumps are sensitive to air Must be prepared for both types of injection ports Filter needles are necessary for safe administration of certain medications Use of volumetric syringe Equipment needed: Volumetric pump Syringe IV tubing Sharps PPE Medication Gloves 12

13 Use of volumetric syringe Procedure: Observe universal precautions Verify drug order Confirm right patient, right medication, right dose, right route, right time Confirm patient has no allergies to medication When possible, explain to patient what medication you are administering and why Use of volumetric syringe Procedure: Turn pump on, and calculate required amount of fluid to be infused during transport Draw medication into syringe, expelling all air Attach syringe to port on tubing that does not have drip set Place syringe into pump you are using, and administer medication Record time of drug administration in the PCR Evaluate patient for desired effects of medication and any adverse effects Use of volumetric pump Equipment needed: Volumetric pump Medication Gloves IV tubing 13

14 Use of volumetric pump Procedure Observe universal precautions Verify drug order Confirm right patient, right medication, right dose, right route, right time Confirm patient has no allergies to medication When possible, explain to patient what medication you are administering and why Use of volumetric pump Procedure Turn pump on, and prime medication tubing to ensure all air is out of the system so that no alarms sound Select channel to administer medication, then insert cassette into channel on pump Close channel door, then select channel from main menu Choose infusion type, either drug calculator or rate, and volume to be infused Use of volumetric pump Procedure Select rate, and program that number into the pump Attach tubing to patient, and begin infusion Record time of drug administration in the PCR Evaluate patient for desired effects of medication and any adverse effects 14

15 Drug calculators Includes information only on limited number of medications Can make titration of critical medication quicker and easier Fluid warmers Patients who require rapid fluid resuscitation or large amounts of transfused blood are at risk for developing hypothermia Can help prevent hypothermia If your unit does not carry a fluid warmer, request your service obtain a soft-sided cooler and heating pad 15

16 HELLP syndrome Hemolysis Elevated liver enzymes Low platelets Believed to be variant of preeclampsia Result is deposition of fibrin in lumen of blood vessels and production of several endogenous factors HELLP syndrome Goals: Correct low platelet count Correct hypertension Prevent seizures HELLP syndrome Dexamethasone (Decadron) Dosage of 10 mg IV every 12 hours improves BP, urine output, platelet count, and liver function Studies have shown that high dosage of steroids decreases acuity of the syndrome and reduces need for additional treatments Helps prolong time to delivery of the baby Maturation of fetal lungs has improved with steroid administration 16

17 HELLP syndrome Magnesium sulfate Treatment of choice for seizures from eclampsia Administered for prophylactic treatment of seizures Can cause toxicity in patients Superior to phenytoin for prevention of eclampsia and associated seizures HELLP syndrome Phenytoin Used when magnesium sulfate is contraindicated BP and heart rate must be monitored every 5 min Therapeutic range is narrow HELLP syndrome Hydralazine (Apresoline) Used for treatment of maternal hypertension Decreases BP Reduces risk for placental abruption, seizure activity, and maternal cerebral hemorrhage Initiated with systolic BP more than 160 mm Hg or diastolic pressure more than 105 mm Hg 17

18 HELLP syndrome Labetalol Alternative medication Can cause less maternal hypotension than hydralazine HELLP syndrome When administering multiple medications, consult drug compatibility reference Additional access is needed After initiation of 18-gauge IV line in left antecubital fossa, the paramedic would be ready to transfer medications to infusion pump Syringe and half set could be used Must label syringe with medication and concentration to calculate drip rate in case of pump failure HELLP syndrome Calcium gluconate Magnesium toxicity treatment Administer 10 to 20 ml 10% IV push 18

19 Treatment after cardiac arrest or inferior MI Eptifibatide (Integrilin) prevents additional cardiac ischemia Amiodarone (Cordarone) prevents additional cardiac arrhythmias Midazolam (Versed) continues appropriate sedation Vecuronium (Norcuron) treats neuromuscular paralysis Treatment after cardiac arrest or inferior MI When multichannel pumps are used, only 3 medications can be connected to electric pump If more than 4 infusions, one should be put on Dial-A-Flo or converted to IV bolus IV bags may rest directly on patient Treatment after cardiac arrest or inferior MI Vecuronium infusion To maintain, place medication bag into pressure bag and add Dial-A-Flo Is mixed with 100-mL bag of fluid and makes pressure bag use difficult Duration of action of 25 to 40 min Pump failure Convert medication to intermittent boluses 19

20 Diabetic ketoacidosis Must decide how to manage fluids during transport Must decide how to transport fluids Volume-control chamber to administer fluids to pediatric patient May fit into infusion pump or flow strictly to gravity Manufactured to provide additional protection against accidental administration of excessive fluid Must be closely monitored to prevent fluid overload If filled with desired amount of fluid and clamped off to bag, impossible to administer excessive overload Diabetic ketoacidosis Insulin Can be drawn into syringe and infused with half set through infusion pump Usually mixed at a 1:1 concentration of medication and fluid Ensure you have enough medication on hand Closed head injury Must help decrease swelling while supporting physiologic status Increased cerebral edema Can result in herniation Causes decrease in amount of perfusion to the brain Monitor BP 20

21 Closed head injury Cerebral blood flow calculation: Difference between mean arterial pressure (MAP) and ICP divided by cerebral vascular resistance Cerebral perfusion averages 50 ml of blood/100 g of brain tissue per min Cerebral perfusion pressure (CPP) is often used Goal of 70 for CPP is needed to ensure adequate cerebral perfusion Closed head injury Cerebral blood flow calculation: Increases in ICP and decreases in MAP can result in insufficient blood flow to the brain Systolic BP of at least 110 mm Hg is needed to ensure minimal blood flow to the brain In cases when high ICP is suspected, systolic BP must be higher Closed head injury Cerebral blood flow calculation: MAP greater than 90 mm Hg with ICP of 20 mm Hg results in CPP of at least 70 mm Hg If patient has systolic BP lower than 110 mm Hg, fluid resuscitation is necessary 21

22 Closed head injury Sedation and neuromuscular blocking agents may be needed to help control oxygenation and ventilation to ensure appropriate CO 2 level Continuous O 2 saturation monitoring is recommended with desired level greater than 90% In unresponsive patient with extensor posturing and flaccidity, recommended ventilation rates are: 20 breaths/min for adults 30 breaths/min for children 35 to 40 breaths/min for infants Closed head injury In absence of herniation, avoid hyperventilation In patients without posturing or flaccidity, CO 2 level of 35 to 40 mm Hg is desired Use end-tidal CO 2 monitoring to calculate CO 2 level Expired CO 2 is 3 to 5 mm Hg less than arterial CO 2 Closed head injury Propofol (Diprivan) Hypnotic medication of choice Decreases cerebral metabolism Easily titrated and has short half-life Phenol derivative classified as anesthetic Used for induction and maintenance of anesthesia 22

23 Closed head injury Propofol (Diprivan) Used for sedation in intubated patients in intensive care Mechanism of action is dose dependent and causes CNS depression, rapid hypnosis, and minimal excitation Onset of action is 10 to 40 sec Duration of action is 3 to 10 min Closed head injury Fentanyl citrate (Sublimaze) Can potentiate propofol with minimal hemodynamic effects Mannitol (Osmitrol) Osmotic diuretic Used for cerebral edema Expands intravascular volume while decreasing viscosity of blood Can crystallize in cold temperatures Closed head injury When administering medication, be sure to label syringes with medication and concentration Important if pump failure Pump should have drug calculator so drug can be titrated as necessary during transport 23

24 Burn injury Fluid replacement Prevents hypovolemia Large amounts of crystalloid replaces intravascular fluid loss that results from shifts to interstitial spaces Burn injury Parkland formula of burn resuscitation 2 to 4 ml x weight in kilograms x total body surface area burned Half of total fluid is administered in first 8 hours of injury, and remaining half is administered during the following 16 hours Must know how to calculate total body surface area (TBSA) burned Burn injury Maintenance fluid of D 5 Ringer lactate (D 5 LR) is administered to children Decreased glycogen stores and needed replacement of glucose Calculation of rate of resuscitation for remaining 16 hours: Take total 24-hour resuscitative fluid requirements, divide by 2, then divide by 16 24

25 Burn injury Urine output is closely monitored in burn patients to help determine whether patients are receiving adequate amount of resuscitative fluid Adults: Total 0.5 ml/kg per hour Pediatric: 1 ml/kg per hour if weight less than 30 kg Foley catheter and/or strict intake and output recording is recommended if patient has sustained burn large enough to require fluid resuscitation Burn injury Wallace rule of nines and rule of palms Most commonly used method of estimating TBSA of large burn injuries Rule of nines divides patient s BSA into units divisible by 9 (see Fig ) Rule of palms estimates burns that are either scattered or comprise less than 10% TBSA 25

26 Burn injury Lund-Browder chart is more accurate calculator of TBSA Not used in field because rules of nines and palms are faster Burn injury Calculate only areas of partial- and full-thickness burns for TBSA New method of determining burn size and fluid resuscitation: rule of ones Uses resuscitation index with reference to table to complete determination of fluid needs in a more simplified operation Fluid resuscitation is calculated by adding a few numbers and referring to a simple table 26

27 Burn injury Burn size score (BSS) Using same anatomic regions as rule of nines, assign score of 1 if more than 50% of that region is burned Use score of ½ if region is burned less than 50% Add all points to obtain BSS and round up total Cross-reference patient s weight and BSS to determine fluid rate Blood administration No different than other medications administered Has adverse effects and signs/symptoms Factors considered: Compatible fluids Filtration Time Transfusion reactions 27

28 Blood administration Blood tubing incorporates filter to allow easy administration Prevents administration of cells that have clotted in tubing Y portion of tubing allows bag of normal saline to be infused after blood administration to prevent wasting blood in tubing Blood administration When administering blood through smaller-bore IV catheters, saline may be needed to help dilute blood and prevent complications in catheter tip Degradation of blood components must be prevented Must be administered within 30 min of removal from refrigerator If unit reaches 10 C (50 F), RBCs degrade and blood must be discarded Pooled platelets require blood to be discarded Blood administration Monitoring for transfusion reactions Most dangerous aspect of blood administration Must monitor vital signs, patient symptoms, respiratory status If a transfusion reaction is suspected, stop transfusion and flush line with saline 28

29 Blood administration Blood products Need for an additional blood product has risen Blood substitutes or O 2 carriers are in phase II and III in clinical trials Two classes being developed: Perfluorocarbon-based products Hemoglobin-based O 2 carriers Blood administration Blood products Advantages of blood substitutes: Eliminate risk for bloodborne pathogens Eliminate need to crossmatch patients Have long shelf life that does not require special handling or storage Pharmacologically alter O 2 transport Improve microcirculation by reducing risks for small clots Prevent adverse effects of blood that has begun to degrade from increased shelf life Questions? 29