Fall 2009 / Spring 2010 Recertification Pre-Course Reading Primary Care Paramedic - 1 -
Introduction & Expectations Welcome to your 2009/2010 recertification. The SWORBH staff is excited to provide a Pre-Course Package to you that reflects educational needs across the region. There are 4 components to your Pre Course Package The Pre Course Reading, the Updated SWORBH PCP Protocol, the Pre Course Quiz and a contact information sheet for you to complete. You are responsible for reviewing the Pre-Course reading and the protocols in detail prior to attending your Recertification Day. The recertification day will review some but not all of the information in this package. The SWORBH Educators will highlight some changes from your current protocols during the recertification day but will NOT review each protocol. By thoroughly reviewing the precourse package and protocols (and any reference materials you enjoy), you will be able to: 1. Identify the key components of an ECG rhythm, and analyze (interpret) basic rhythms. 2. Select the appropriate treatment of various medical and trauma condition as per the protocols. 3. Distinguish between various medical conditions based on the patient s signs, symptoms, and history. 4. Calculate various dosages of medications and drip rates of intravenous fluids. Attached you will find a quiz that you are required to complete and bring to class with you. Failure to bring the completed quiz with you at the start of class will result in your being unable to attend and you will have to re-schedule your recertification. To be successful in your recertification you must obtain a mark of 80%. An Agenda outlining the day s activities is included in this package. Please note that the start time will depend on the service that you work for. Classes will start promptly. Arriving late is disruptive and will require that you reschedule your recertification. We will be asking for your feedback at the end of the day. Your honesty and constructive criticism are appreciated and will assist us with developing programs to best suit your needs. A contact sheet is included with this material. You are asked to complete the form and bring it with you to your class. This information will be used to update our database and will not be shared. Your address and contact information are important in the event that we are required to reach you about quality assurance issues, training, or to provide references that you may request in the future.. If you have any questions about the contents of this package don t hesitate to contact the Southwest Ontario Regional Base Hospital. - 2 -
Table of Contents PCP Recertification Day Agenda...4 Pre-Course Reading Material...5 Basic Rhythm Interpretation...5 Let s review the Basics...5 1. Rate...7 2. RHYTHM (R-R Interval)...8 3. P-R INTERVAL...9 4. P-QRS-T RELATIONSHIP...9 Review of some common ECG tracings...10 Cardiac Arrest Rhythms:...16 Transport of the Arrested Pediatric Patient...19 Pediatric Defibrillation Notes:...20 Review of Traumatic Termination of Resuscitation (TOR) Guidelines...22 Cerberovascular Accident (CVA) or Stroke Review...25 Medical Math...28 Intravenous Review (Certified Paramedics Only)...34 *** SWORBH PCP Regional Protocols included under separate cover. - 3 -
PCP Recertification Day Agenda Please note that start time may vary by EMS Service YOU are responsible for knowing the start time for your service s recertification day! Learning Objectives: Given short lectures on both local and regional issues, and appropriate paramedic supplies and manikins, the paramedic will: 1. Demonstrate proper defibrillation of both adult and pediatric patients according to protocol, 2. Calculate medication dosages according to protocols, and administer the medication by IM injection, and (where certified) by IV, 3. Control an airway by manual means, oral/nasal airways, and (where certified) by supraglottic airways, and provide ventilation by means of a BVM, 4. Describe proper assessment and treatment of patients with various medical and trauma conditions as per approved protocols, as evaluated by the learner and facilitator during practical skill stations and oral scenarios. Time Topic 09:00 10:00 Presentation of Regional Material 10:00 11:00 Presentation of EMS Service Specific Material 11:00 12:00 Lunch Break 12:00 14:00 Skills Stations (4 Stations, 30 min each) 14:00 16:00 Scenario Stations (4 Stations, 30 min each) - 4 -
Basic Rhythm Interpretation Pre-Course Reading Material This module will review ECG interpretation, focusing on the most common rhythms paramedics may encounter. It is important to recognize rhythms as they can indicate potentially life threatening problems in a patient that appears well and can assist in the diagnostic and therapeutic work up of a patient. Let s review the Basics 1) SA Node a. This is where normal or sinus rhythm cardiac electrical activity begins b. Represented by P wave (also represents simultaneous atrial contraction) 2) AV node: a. The electrical impulse slows down going through the AV node, which allows for ventricular filling during normal atrial contraction. b. From the SA node to here, it is called the P-R Interval. It represents supraventricular activity, atrial depolarization and the delay through the AV node c. The delay through the AV node itself is represented by an isoelectric line - the P-R segment. 3) Ventricular depolarization a. Represented by the QRS complex. b. The individual deflections: i. Q wave can be normal (septal depolarization) / abnormal (post MI). the first downward deflection after the P wave, but before the R wave ii. R wave is the first upward deflection after the P wave. iii. S wave Is the second downward deflection after the P wave, or the first downward deflection after the R wave. 4) Ventricular repolarization a. represented in the T wave - the wave following the QRS complex. To determine the rhythm, you need to understand how to read an ECG. The ECG paper is designed for a speed of 25 mm/sec. You will notice large squares with smaller - 5 -
squares within them. Each large square consists of 5 smaller squares. The larger squares are 5 mm; therefore each small square is 1 mm. At 25mm/sec., that s 5 large squares per second. The ECG graph paper moves at 25 mm / 1 second, and 25 mm is 5 large squares. Therefore: 5 Large squares = 1.00 seconds ( 5) so, 1 Large square = 0.20 seconds ( 5) and, 5 small squares = 0.20 seconds ( 5) thus, 1 small square = 0.04 seconds Here is an example of a normal ECG tracing The PR Interval should be less than 0.20 seconds. This is 1 large square or 5 small squares The QRS complex should be less than 0.12 seconds. This is 3 small squares (3 X 0.04 = 0.12 sec.) There are 5 rules to follow with ECG interpretation that will describe the rhythm to help you identify it. 1. RATE i. < 60 = Bradycardia ii. 60 100 = NORMAL iii. > 100 = Tachycardia 2. RHYTHM i. Regular ii. Irregular: a. Irregularly irregular - 6 -
b. Regularly irregular c. Chaotic (VF) d. Artifact 3. P-R INTERVAL i. Normal = 0.12-0.20 seconds 4. P-QRS-T RELATION i. is there a P wave for every QRS complex? 5. QRS WIDTH i. 0.08-0.12 seconds? Anything MISSING OR ADDED? 1. Rate Method 1: Count the number of R waves for a six second interval and multiply by ten. (8 R-waves in 6 seconds) X 10 = 80 bpm 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. 1 2 3 4 5 6 3006=50 bpm - 7 -
Method 3: Using the following scale, each number represents a 5mm square 300-150 - 100-75 - 60-50 300150100 75 60 50 2. RHYTHM (R-R Interval) Regular Irregularly irregular Regularly irregular - 8 -
3. P-R INTERVAL Measured from the beginning of the P-wave to the beginning of the Q wave. < 0.20 sec. is the upper end of normal parameter, 1 large square, & 5 small squares 4. P-QRS-T RELATIONSHIP Is there a P wave for every QRS Complex? In other words, did this P-wave generate that QRS complex. 5. QRS DURATION Beginning of the Q-wave to the end of the S-wave. Measured from the beginning of the Q wave to the end of the S wave. Normal width is 0.12 sec or 3 small squares. The conducted rhythm must be supraventricular if the QRS duration is 0.12 sec. ANYTHING ADDED? Premature & Escape beats ANYTHING MISSING? Complexes / Waves / Blocks - 9 -
Review of some common ECG tracings NORMAL SINUS RHYTHM RATE: 60-100 bpm RHYTHM: Regular P-R INTERVAL: < 0.20 seconds QRS WIDTH: < 0.12 seconds P-QRS-T: P for every QRS MISSING/ADDED?: Nothing IDENTIFYING FEATURES: ALL CRITERIA NORMAL SINUS TACHYCARDIA RATE: > 100 bpm but <150 bpm RHYTHM: Regular P-R INTERVAL : < 0.20 seconds QRS WIDTH: < 0.12 seconds P-QRS-T : P for every QRS MISSING/ADDED? : Nothing IDENTIFYING FEATURES: RATE > 100 AND < 150 bpm ALL Other Criteria Normal - 10 -
SINUS BRADYCARDIA RATE : <60 bpm RHYTHM: Regular P-R INTERVAL : < 0.20 seconds QRS WIDTH: < 0.12 seconds P-QRS-T : P for every QRS MISSING/ADDED? : Nothing IDENTIFYING FEATURES: o RATE < 60 bpm o ALL Other Criteria Normal SINUS ARRHYTHMIA RATE: Usually 60-100 bpm RHYTHM: Irregular P-R INTERVAL: < 0.20 seconds QRS WIDTH: < 0.12 seconds P-QRS-T : P for every QRS MISSING/ADDED? : Nothing IDENTIFYING FEATURES : o Slowing of rhythm with respirations. o ALL Other Criteria Normal o This rhythm is considered a normal variant, especially in young patients - 11 -
SINUS BLOCK RATE: < 100 bpm RHYTHM: Irregular P-R INTERVAL: < 0.20 seconds QRS WIDTH: < 0.12 seconds P-QRS-T : P for every QRS MISSING/ADDED? : P-wave @ next expected location. IDENTIFYING FEATURES : o Missing P wave o Dropped QRS complex o P -P Interval = 2 o Usually misses one impulse generation o This rhythm is not considered a normal variant and may only be picked up by the EMS provider with rapid application of the monitor. o If noted by the paramedic, this (as with any potentially pathologic rhythms) should be brought to the attention of the ER staff ATRIAL FIBRILLATION RATE: 40-250 bpm RHYTHM: Irregularly irregular QRS WIDTH : < 0.12 seconds P-QRS-T : No P-waves P-R INTERVAL : No discernable P-waves MISSING/ADDED? : No P-waves IDENTIFYING FEATURES : No discernable P-waves, Irregularly irregular rhythm - 12 -
JUNCTIONAL RHYTHM RATE: 40-60 bpm RHYTHM: Regular QRS WIDTH: < 0.12 seconds P-QRS-T : P waves, if present, inverted. P-R INTERVAL : < 0.20 seconds MISSING / ADDED : Narrow QRS complex with inverted P-wave before QRS complex May also have inverted P-wave after QRS, or no P-wave at all. IDENTIFYING FEATURES : o Narrow complex QRS occurring before next expected QRS complex o P-wave, if present, inverted before the early QRS complex o Rate of 40-60 bpm. FIRST DEGREE AV HEART BLOCK RATE: QRS WIDTH: < 0.12 seconds Sinus rhythm with First Degree AV Heart Block RHYTHM: Regular P-QRS-T: P for every QRS P-R INTERVAL : > 0.20 seconds MISSING/ADDED?: Nothing IDENTIFYING FEATURES: PR Interval > 0.20 seconds ALL OTHER CRITERIA NORMAL - 13 -
SECOND DEGREE AV HEART BLOCK TYPE I WENCKEBACH RATE: < 100 bpm QRS WIDTH: < 0.12 seconds (Not Sinus rhythm with a Second Degree AV Heart Block) RHYTHM: Irregular P-R INTERVAL : Increases P-QRS-T: No QRS for every P-wave MISSING/ADDED?: QRS complexes IDENTIFYING FEATURES: o PR Interval increases until there is a dropped QRS complex after a P-wave. THIRD DEGREE AV HEART BLOCK RATE: < 60 bpm RHYTHM: Regular P-R INTERVAL : Variable QRS WIDTH: > 0.12 seconds P-QRS-T: No QRS for every P-wave MISSING/ADDED?: Nothing IDENTIFYING FEATURES: o P-waves march through the QRS complexes. o No P-QRS marriage o Regular slow ventricular response o Atria & Ventricles are functioning totally INDEPENDENT of each other. - 14 -
PREMATURE VENTRICULAR COMPLEX: UNIFOCAL RATE: Underlying rhythm is... RHYTHM: Irregular QRS WIDTH : > 0.12 seconds P-QRS-T : No P waves before early complex. P-R INTERVAL : < 0.20 seconds MISSING / ADDED : Wide QRS complex for the early complex. IDENTIFYING FEATURES : o PVC - Wide complex QRS occurring before the next expected QRS complex. o No P-wave before the premature QRS complex. o R-wave oppositely deflected to the T-wave on the premature complex, same morphology QRS. - 15 -
Cardiac Arrest Rhythms: This Section discusses the Rhythms you may see in a Cardiac Arrest Patient. Every Paramedic should recognize these rhythms. Some services in the SWORBH now must defibrillate patients < 8 years old based on their ability to interpret these rhythms! All Paramedics should review this section extremely carefully! VENTRICULAR TACHYCARDIA RATE: > 100 bpm RHYTHM: Regular P-R INTERVAL : No P-waves QRS WIDTH: > 0.12 seconds P-QRS-T: No P-waves MISSING/ADDED?: P-waves IDENTIFYING FEATURES: o Wide QRS complexes o No P-waves o Rate > 100 bpm. VENTRICULAR FIBRILLATION COARSE: 1 LARGE square or greater RATE: 400-700 bpm RHYTHM: Chaotic P-R INTERVAL : No P-waves QRS WIDTH: > 0.12 seconds or variable P-QRS-T: No P-waves MISSING/ADDED?: Wide & Bizarre, Chaotic IDENTIFYING FEATURES: o Wide, bizarre o Chaotic rhythm greater than 1 LARGE square. - 16 -
AGONAL RHYTHM (a form of Pulseless Electrical Activity -PEA!) RATE: < 20 bpm RHYTHM: Irregular P-R INTERVAL : No P-waves QRS WIDTH: > 0.12 seconds P-QRS-T: No P-waves MISSING/ADDED?: No P-waves IDENTIFYING FEATURES: o Wide QRS complexes o No P-waves o Slow irregular rhythm with periods of asystole. ASYSTOLE RATE: 0 bpm RHYTHM: None P-R INTERVAL : No P-waves QRS WIDTH: No QRS complexes P-QRS-T: No P-waves MISSING/ADDED?: No P-waves IDENTIFYING FEATURES: o No electrical activity. - 17 -
Pulseless Electrical Activity (PEA) One of the more important ECG tracings that you need to be able to recognize is Pulseless Electrical Activity, also known as PEA. With PEA there is electrical activity with NO mechanical output. Some of the possible causes can include: Tension pneumothorax Cardiac tamponade Hypovolemia Pulmonary embolus Hypoxia Acute MI Hyperkalemia (high potassium) When a patient has been found to be in cardiac arrest (VSA) and has sustained trauma, the paramedic will manage the patient according to the correct medical directive, and will need to determine if the patient is presenting in a PEA rhythm. The Blunt Trauma Protocol states that primary care paramedics (PCP) are to transport a pulseless patient once a no shock advised/check pulse is received, and the monitor shows a heart rate of >0 bpm (ie. PEA!). The PCP are to contact BHP for possible cease resuscitation order if the monitor shows a heart rate = 0 bpm (patients 16 years of age and older). On the monitor you will see Asystole (refer to above). The Penetrating Trauma Protocol states that if the monitor (heart monitor pads applied) shows a heart rate of 0, contact BHP for possible Termination of Resuscitation order (patients 16 years of age and over). If the monitor shows a heart rate >0, and the nearest ED or trauma centre is <20 min away, initiate transport. However, if the monitor shows a heart rate >0 and the nearest ED or trauma centre is > 20 min away, then contact BHP for a possible Termination of Resuscitation order (patients 16 years of age or older). Any pulseless patient with are rhythm or electrical activity that is not Ventricular Tachycardia, Ventricular Fibrillation or Asystole is in PEA! - 18 -
Transport of the Arrested Pediatric Patient At the direction of the Ministry of Health, on April 1 st, 2009 the transport criteria for the medical cardiac arrest patient changed. This section highlights those changes. Transport in the following circumstances: 1) 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 on-scene AED equipped first responders. OR 2) In unusual circumstances such as pediatric patients < 16 years old, paramedics may consider early transport after the first no shock message (providers with attenuation cables and pads in AED mode) or PEA and/or Asystole with no palpable pulse (providers with manual defibrillation capability). OR 3) When a ROSC (return of spontaneous circulation) is detected. OR 4) You have been directed to transport by the Base Hospital Physician. - 19 -
Pediatric Defibrillation Notes: The Provincial protocols for the defibrillation of pediatric patients also changed on April 1 st 2009. Across the SWORBH area each services has selected how to implement this change based on their equipment and resources. The basic choices for defibrillation of pediatric patients was between one of 3 options: 1) Manual Defibrillation of patients >30 days and < 8 years old 2) Semi automated defibrillation with Attenuator Cables for patients > 1 year old and < 8 years old 3) Semi automated Defibrillation of all patients > 1 year old with adult cables and energy. On the recertification the SWORBH Educators will review your services pediatric defibrillation choice. However, these notes below apply to ALL services: Deliver single shocks only. Transport after 1 non-shockable rhythm or following 4 shocks/analysis have been delivered. Remember; we prefer you do not stay on scene when resuscitating a pediatric patient in a non-shockable rhythm. Load and Go after you interpret a rhythm that is not Shockable. Patients age > 8 years & < 12 years will be defibrillated as preprogrammed by the Base Hospital. After a ROSC (Return of Spontaneous Circulation) on scene, if the patient rearrests enroute, bring the ambulance to a complete stop, analyze the rhythm and treat accordingly. o Shockable Rhythm- Defibrillate and resume CPR with no further stops. o Non-Shockable Rhythms- Check pulse, if no pulse resume CPR and transport with no further stops. - 20 -
Summary PCP s should defibrillate patients between 1 year old and 8 years old based on their services equipment and choice o Greater than 30 days if using manual defibrillation and energy calculation Transport patients < 16 years old after: o One no shock indicated PCP s in SAED Mode OR o One non VF/VT rhythm analysis PCP s with manual defibrillation program OR o 4 shocks delivered - 21 -
Review of Traumatic Termination of Resuscitation (TOR) Guidelines The highlights of this protocol are attached below for your review. The application of the TOR has generated significant discussion throughout the region due to the manner in which it was applied. The Southwest Medical Directors have reviewed this directive and believe the following When a patient meets the indications for Termination of Resuscitation from trauma, the paramedic is to patch to the BHP The BHP always has the ability to insist that the patient has resuscitation initiated and the patient transported The paramedic must be able to gain physical access to the patient in order to gather the necessary information for implementation of the directive In situations of prolonged extrication, the paramedic should remain on scene until access is obtainable for assessment of vital signs and application of the monitor The police should remain with the deceased until the coroner attends to formally release the body If the patient is in the ambulance when TOR is granted by the BHP the ambulance is the scene of death. If the paramedic is unable to connect to a BHP, then rapid transport is to be initiated with CPR and BVM. - 22 -
Highlights of Actual Traumatic Protocols: When a patient is found to be in cardiac arrest (vital signs absent- VSA) and has sustained trauma, the Paramedic will manage the patient according to the following protocol: Indications: A patient who is in cardiac arrest (vital signs absent) secondary to obvious severe blunt trauma. Conditions: Defibrillator use: AED without pediatric attenuator cables, applies to patients >8 years old. AED with automated rhythm analysis and pediatric attenuator cables applies to patients >1 year old and <8 years old. Manual defibrillation, applies to all patients > 30 days old ages. Patch for consideration of trauma- Termination of Resuscitation (trauma- TOR): Patient must be >16 years old to consider TOR. All patients <16 years old will be resuscitated and transported Contraindications: Patients who meet conditions for obvious death (as per Basic Life Support Patient Care Standards) or who meet conditions of the DNR Standard. Procedure: Blunt Trauma: Confirm cardiac arrest by absence of spontaneous respiration and palpable pulse in a patient with obvious external signs of significant blunt trauma. Initiate management and CPR according to the Basic Life Support Patient Care Standards for the Trauma Patient. (including immobilization as required) Attach AED/Defibrillator pads (as per the above conditions). - 23 -
If the patient is in a Shock Advised rhythm, deliver a single shock. Continue CPR if needed and transport. No further AED analysis to be done enroute. If No Shock Advised/Check Pulse, check pulse and continue CPR if needed. If no pulse and: Monitor heart rate >0, initiate transport. Monitor heart rate is 0, contact BHP for possible Trauma-Termination of Resuscitation (Trauma-TOR) only for patients >16 years old. Penetrating Trauma: Confirm cardiac arrest by absence of spontaneous respiration and palpable pulse in a patient with obvious external signs of significant penetrating trauma. Initiate management and CPR according to the Basic Life Support Patient Care Standards. Do not attach AED/Defibrillator pads. Attach monitoring electrodes. If monitor heart rate is 0, no pupillary response, and no spontaneous limb movement, contact BHP for possible Termination of Resuscitation (Trauma TOR) only for patients >16 years old. If monitor rate is >0, and nearest ER <20 minutes away, initiate transport. If monitor rate is >0, and ER is >20 minutes away, no pupillary response, and no spontaneous limb movement, contact BHP for possible Termination of Resuscitation (Trauma- TOR) only for patients >16 years old. Remember: the 20 minutes Transport time includes on scene time. If no obvious external signs of significant penetrating trauma, consider medical cardiac arrest and treat according to the appropriate Medical Cardiac Arrest Protocol. - 24 -
Cerberovascular Accident (CVA) or Stroke Review Stroke is a common presentation that paramedics must recognize. Many services in the SWORBH area have bypass protocols in place that enhance patient care by transporting potential stroke patients directly to a centre that offers thrombolytic ( clot busting ) therapy. Below is a basic review of Stroke care. Suspect Stroke: You should consider the diagnosis of Stroke in all patients presenting with new onset: Speech deficit and/or Unilateral face, and/or limb weakness Assessment: Assume life/limb/function threats due to intracranial/intracerebral hemorrhage and/or vascular obstruction. Consider other potentially serious conditions that may mimic a CVA: o Hypoglycemia o Central nervous system (CNS) infection, e.g. meningitis o Hypertensive emergency o Drug ingestion e.g. cocaine (especially if a suspected CVA occurs in a patient <40 years old) Perform the primary survey. Elicit history- determine if the patient is a diabetic. Initiate cardiac monitoring and obtain Vital Signs Make a preliminary transport decision. Obtain blood glucometry measurement Perform minimum secondary survey physical assessments: o Head and Neck: assess pupils (size, equality, reactivity); note loss or abnormality of usual speech; inspect for facial asymmetry. - 25 -
o Central Nervous System: sensory loss (asses light touch); motor function loss e.g. hand grips, arm/leg movement- spontaneous or upon request. o Baseline Glascow Coma Score: note if verbal response is affected by loss/impairment of speech. o Note incontinence of urine/stool (if obvious) Perform other secondary assessments: o Injury assessment: if history, patient s condition and/or scene observations are suggestive of a fall or other trauma. o Neck: flex to assess stiffness and pain response if a central nervous system infection is suspect; (exception- if spine injury is suspected). Make a second transport decision if still on scene. Management: o Specific to cerebrovascular accident: o Secure the airway, assist ventilation as required; o Administer high concentration oxygen; initiate rapid transport. o Keep patient movement to a minimum, provide comfort and reassurance. o Ensure adequate support for the patients body/limbs during lifting. o Position the patient semi-sitting if conscious, or in the recovery position if the level of consciousness is decreased or there is excessive oral secretions, vomiting or inability to swallow saliva. Continually observe and manage the patient s airway. o If the patient is unable to close one or both eyes, gently close the eyelids manually, leave contact lenses in place. o Place extra padding and support beneath paralyzed limbs. If necessary, apply tape or tape plus a gauze dressing or eye pad to keep the eyes closed. Current brands of contact lenses may be left in the eyes of an unconscious patient for up to 24 hours without damaging the cornea. o Manage other identified problems as per specific standard of care. - 26 -
Transport o Transport minimum code 3. o o Transport Code 4 if patient qualifies for a Stroke Bypass Protocol o Enroute: monitor, re-evaluate and manage as required, prepare for expected problems: o emesis o possible airway obstruction (if loss tongue control, gag reflex). o agitation, confusion, aggressive behavior. o decreased level of consciousness, seizures. - 27 -
Medical Math Although many paramedics wish it wasn t Math is an important part of what you do every day! ACR audits, last years PCP recertification and conversations with individual medics have highlighted to the SWORBH staff that we need to review basic medical math again this year. Conversions Common Prefixes Used in Medication Calculation Prefixes Calculation Examples of Reverse Equivalents kilo (k) 1000 x base unit 1 kg = 1000 g 1000 g = 1 kg centi (c) 1/100 of base unit 1 cm = 1/100 m 1/100 m = 1 cm milli (m) 1/1000 of base unit 1 ml = 1/1000 L 1/1000 L = 1 ml micro (µ or mc) 1/1000000 of a base unit 1 mcg = 1/1000000 g 1/1000000 g = 1 mcg This applies for all systems of measurement: Weight (solids or mass): gram (g) Length: meter (m) Volume (liquid or fluid): liter (L) Conversion of Kilograms and Pounds The equivalent to remember is 1 kg = 2.2 lb Ex: If a patient weighs 154 lb, divide 154 lb by 2.2 lb/kg to determine the weight in kilograms. 154 lb = 70 kg 2.2 lb/kg Conversion of Milligrams, Micrograms, and Grams To convert grams to milligrams, multiply grams by 1000. Remember that every 1 g contains 1000 mg; this can be written as 1000 mg/g. Example: How many mg are present in 5 grams? - 28 -
5 g x 1000 mg = number of milligrams 1 g 5 x 1000 mg = 5000 milligrams The same process can be used to convert milligrams to micrograms. milli means x 1000, or add 3 zeros micro means x 1000000, or add 6 zeros To convert milligrams to grams (smaller to larger), divide the number of grams by 1000 or simply move the decimal point three places to the left. BASIC CONVERSIONS 1 kg = 1000 g 1g = 1000 mg 1 mg = 1000 mcg 5000000 mcg = 5000 mg = 5 g = 0.005 kg 1 L = 1000 ml or 1000 cc (1mL = 1 cc) 1 kg = 2.2 lb Remember: 1 mg does not equal 1mL or 1 cc. A mg refers to the amount of drug and ml or cc refers to the amount of fluid which is the carrying solution. Ex. Epi 1mg/1ml or gravol 50mg/ml. Dilutions: refer to the intensity or strength of a drug. The same drug can come in various concentrations such as epinephrine 1:1000 in 10 ml or 1:10000 in 10 ml. Formulas Formulas are used to determine how much of a given drug is to be given to a patient. They should be used in conjunction with the basic conversions explained previously. Four basic often used formulas are discussed below. - 29 -
Formula 1: Single dose (bolus or IM injection): Desired dose x volume (quantity) = X Dose on hand 1 also known as: D x V = X Doctors Order X Volume (ml or cc) = X A Available Drug 1 Formula 2: To infuse a measured amount of fluid in a set amount of time (e.g. fluid challenge) Drip factor: Drops/mL of the IV set. This is clearly outlined as a number ex.10gtts/ml =10gtts= 1ml 15 gtts/ml =15gtts =1ml, 20gtts/ml = 20gtts=1ml (Drip factor) Total volume x (drops/ml of IV set) = drops/min Time in minute Formula 3: Drip (infusion) not based on weight (e.g. lidocaine drip): Dose desired x drops/ml IV set = drops/min Dose on hand 1 Formula 4: Drip (infusion) based on weight (e.g. dopamine drip) Dose desired x weight (lb) = dose desired kg 2.2 lb/kg dose desired x wt (lb) kg 2.2 lb/kg dose desired x drops/ml of IV set = drops/min dose on hand 1-30 -
Application of formula 1: A 64 yr/old woman is enjoying a round of golf when she is suddenly stung by a bee. Because she is allergic to bee stings, she quickly heads back to the clubhouse and calls 911. On arrival, the patient is in mild distress, with large hives appearing on her face and neck. Because of her age and the relatively mild signs and symptoms at this point, you avoid the use of epinephrine and choose to administer diphenhydramine (Benadryl) 25mg IM. The prefilled syringe reads 50 mg/ml. How many milliliters should you administer? Answer: Desired dose x volume (quantity) = Dose on hand 1 25 mg x 1mL = 50mg 25 mg x 1mL = 25 x 1mL = 25 = 0.5 ml 50 mg 50 50 Administer 0.5 ml of Benadryl IM to the patient. Remember: whenever the dosage is < 1, always place a 0 before the decimal point Application of formula 2: Administer 60 ml of fluid containing a medication over a 60 minute period. Use a microdrip infusion set that delivers 60 gtt/ml. How many drops per minute should be administered? Answer: (drip factor) Total volume x drops/ml of IV set = drops/min Time in minutes 60 ml x 60 gtts/ml = 60 min 60 ml x 60 gtts/ml = 60 x 60 gtts = 3600 gtts = 60 gtts/min 60 min 60 min 60 min - 31 -
Application of formula 3: Administer an epinephrine infusion at 4 mcg/min. Add 1 mg of epinephrine to a bag of 250 ml normal saline. Use a microdrip infusion set that delivers 60 gtt/ml. What is the drip rate in drops per minute? Answer: DD (in minutes) x gtt/ml of IV set = gtt/min DH ** Begin by converting Epi mg Epi mcg to attain dose required before adding it to the 250 ml bag calculation.** 1 mg = 1000 mcg, so DH (dose on hand) is 1000mcg/250mL = 4 mcg/ml 4 mcg/min x 60 gtt/ml = gtt/min 4 mcg/ml 4 mcg/min x 60 gtt/ml = 4/min x 60 gtt = 240 gtt/min = 60 gtt/min 4 mcg/ml 4 4 Or you can use a 2 step calculation: by first figuring out ml/min then gtts/min. ** Begin by converting Epi mg Epi mcg.** step1 DD (Dose in Minutes) x Volume DH (Dose on Hand) now needed in mcg 1 4mcg/min x 250 ml (volume) = 4/min x1ml (volume) = 1ml/min 1000 mcg 4 4 2) Drip factor of IV set needed is 60gtts/ml = 1ml = answer 60gtts/min Which means it takes 60 drops or gtts to equal 1 ml. Therefore, in this case. 60gtts x ml = how many gtts per minute are required. Answer= 60gtts. Application of formula 4: You are transporting an elderly woman with a history of multiple cardiac events to the hospital. Enroute, her blood pressure begins to drop even though her cardiac rhythm - 32 -
shows only sinus tachycardia at 120 beats/min. You contact base hospital and are given an order to administer dopamine at 2mcg/min and to titrate to a blood pressure of 100 mmhg systolic. You are carrying a pre-mixed bag of dopamine at 800 mg in 500 ml. The patient weighs 110 lbs. The first calculation that needs to be made is to convert the patient s weight from pounds to kilograms. 110 lb = 110 = 50 kg 2.2 lb/kg 2.2/kg The second calculation is to determine the strength of dopamine on hand (dopamine is always calculated in micrograms). 800 mg = 800000 mcg which is added to 500 ml of NS 80000 mcg = 1600 mcg/ml 500 ml DD x kg x drip rate (always in microdrip set 60 gtt/ml) = gtt/min DH 2 mcg x 50 kg x 60 gtt/ml = gtt/min 1600 mcg 2 mcg/kg/min x 50 kg x 60 gtt/ml = gtt/min 1600 mcg/ml 2/min x 5 x 6 gtt = 60 = 3.75 gtt/min (or 4 gtt/min rounded) 16 16 Pediatric Weight Calculation: Weight = 10 + (age in years X 2) - 33 -
Intravenous Review (Certified Paramedics Only) The purpose of an IV: Restore or replace intravascular volume Administer medications Maintain venous access in emergency situations Obtain blood samples Provide a route for nutritional support (not a pre hospital concern) Anatomy Review: Veins more superficial carry blood toward the heart blood is dark red contain valves Arteries located deeper carry blood away from the heart blood is bright red pulsatile Selecting a common site for cannulation Hand Veins Smaller than forearm veins Low perfusion states, circulation reduced Arm Veins Larger and straighter Accommodates larger catheters and volumes - 34 -
The most common accessible sites for cannulation Sites to Avoid Limbs with Fractures Burns, infections, rashes Veins with obvious stenotic valves Veins around joints for long term infusions Dialysis shunts Paralyzed extremities Extremities with signs of several venipunctures Using large access areas (antecubital) unnecessarily as a primary site Avoid the use of lower extremities Arm with lymphedema in breast cancer survivors Catheter Guidelines IV catheters measured by inner diameter and by length 24 Gauge Newborns or neonates 22 Gauge Fragile small veins, or pediatric population, elderly 20 Gauge Most adults/adolescents, medications, TKVO, most common infusions/meds, - 35 -
18 or 16 Gauge Adult/adolescent only, volume replacement, trauma, colloids and blood replacement. - 14 Gauge garden hose not frequently used in the field ***Note: use at least a 20 gauge for D50. If you cannot get a 20g - Do not give D50. Administration Set Types Micro drip : 60gtts =1 ml Macro drip: 10gtts, 15gtts, 20gtts To Keep Vein Open (TKVO) IV rates Using only 0.9% saline: > 40kg = 30-60ml/hr < 40kg = 15ml/hr via microdrip or buretrol (60gtts/ml) Review of N/S Bolus Initiation Protocol The hypotensive / hypovolemic patient without signs of fluid overload on chest auscultation may receive: - >40kg pt. must have a SBP of <100. o Bolus of 20ml/ kg with checking vitals and chest auscultation after every 250cc. - < 40kg pt. must have SBP < (2x pts age +70). o A fluid bolus to a maximum of 10ml/kg with chest auscultation and vitals after every 100cc. Calculation review: Pt weight 100kg = 20ml x 100kg =2000ml. Pertinent ACR Documentation Date and time of insertion Gauge of catheter Type and amount of solution hung Site of venipuncture Rate of infusion Total infused (in fluid intake area of ACR) Any reactions??? Use appropriate codes *** Note: It also as important to document missed IV attempts. This may assist patient outcome. The code for a missed attempt is #350. - 36 -
Ex. Time Code Procedures Results Initial 0845 345 18gx30mm in Rt infusing well JD Forearm with 250ml TKVO @ 30ml/hr 0.9% N/S. In the case of traumatic hypovolemia, all attempts of gaining IV access should not delay transport to the closest appropriate facility - 37 -