2010 Buncombe, Madison, Yancey Protocol Update

1. 2010 Buncombe, Madison, YanceyProtocol Update EMT-Intermediate

2. Direct Laryngoscopy (1 of 2) • Visualization of the airway with a laryngoscope for the removal of the foreign body in unresponsive patients • If you are unable to relieve a severe airway obstruction in an unconscious patient by current standards, then: • Insert the blade of the laryngoscope into the patient’s mouth.

3. Direct Laryngoscopy (2 of 2) • If you see the foreign body, carefully remove it from the upper airway with the Magill forceps • Prepare to suction and use Bag Valve Mask if necessary

4. Removal of an Upper AirwayObstruction With Magill Forceps Step 1 Step 2 Step 3 Step 4

5. Fever/Infection Control Protocol • Buncombe, Madison, Yancey EMS systems are no longer giving ibuprofen for fever prehospital. • Acetaminophen will take its place and has multiple uses. • Let’s look at Acetaminophen….

6. Acetaminophen • Classification • Non-narcotic analgesic, antipyretic. • Prehospital Indication • Fever reduction • Pain Control • Pain Severity >6 out of 10

7. Acetaminophen • Actions • Unlike aspirin, acetaminophen has little effect on platelet junction, does not affect bleeding time, and generally produces no gastric bleeding. Produces analgesia by unknown mechanism, perhaps by action on peripheral nervous system, reduces fever by direct action on hypothalamus heat-regulating center with consequent peripheral vasodilations, sweating, and dissipation or heat.

8. Acetaminophen • Dosage • Adult • 1000 mg PO (1 gram) • Pediatric > 3 months. • 10 mg/kg PO • Normal Packaging • Children’s Acetaminophen liquid suspension 160 mg/5 ml or 32 mg/ml

9. Acetaminophen • Contraindications/Adverse Reactions • Hypersensitivity to acetaminophen or phenacetin. • Malnutrition can lead to acetaminophen toxicity. • Avoid use in patient with sever liver damage.

10. TORADOL® Toradol (Ketorolac)

11. Toradol History • Developed by Roche • First NSAID in its class to be approved as injection in the USA on November 30, 1989 • Generic name: Ketorolac

12. Pharmacodynamics Ketorolac inhibits the cyclo-oxygenase enzyme system and hence synthesis prostaglandins. It is considered to be a peripherally-acting analgesic. It does not have known effects on opiate receptors. It has no intrinsic effects on respiration unlike opioid related respiratory depression or sedation. Ketorolac has no significant CNS effects and possesses no sedative properties.

13. Pharmacokinetics On Set 30 Minutes Peak Effects 45-60 Minutes Duration Varies Half Life 4-6 Hrs Half life in Pt’s 65 or older 5-7hrs Max 5 day use

14. Indications Moderate to severe acute pain in absence of trauma Moderate to severe acute pain in a non- suspected surgical candidate.

15. Contraindications • Ketorolac should not be used by: • Patients with known hypersensitivity to NSAIDs. • Patients with known allergies to Aspirin or NSAIDs. • Patient with pre or post heart bypass surgery. • Renal Failure • Trauma with suspect surgery (ie: fractures) • Just be aware of potential bleeding issues and report you gave Toradol upon arrival at ER.

16. IV or IM Adult Dosage: 30mg slow IVP, or IM. Pediatric Dosage: Not used.

17. Precautions Gastric Bleeding Peptic Ulcers Renal Disease Heart bypass or Heart failure

18. Side Effects Abdominal Pain Constipation/diarrhea Heartburn Nausea/vomiting GI Ulcers Abnormal renal function HTN Dizziness Increased Bleeding time Sweating Edema Headache Injection site pain Rashes

19. CPAP Use and Operation

20. With the arrival of our new CPAP devices comes a responsibility to learn everything we can about what this device is for and the proper way to use it. Please take time to educate yourself about this important piece of equipment.

21. What is CPAP? • Continuous Positive Airway Pressure (without getting into a lot of physics) uses the basic principle that by applying a tight fitting mask and using a regulator, designed to provide a high flow of a variable or fixed oxygen concentration, and (most importantly) by attaching a flow restriction device at the exhalation port of the mask, it is possible to have the patient’s airways placed under a constant level of pressure throughout the respiratory cycle.

22. What do you need to make CPAP work? • Oxygen source capable of delivering 50 psi • Flow regulator which delivers either a fixed or variable oxygen concentration. The flow generator works by what is known as the venturi effect. When you attach it to the primary regulator of the oxygen cylinder and deliver 50 psi through it, the device "sucks" in room air which is used to dilute the 100% oxygen from the cylinder.

23. What do you need to make CPAP work? • Tight fitting mask to which the oxygen/air mixture output of the generator is attached and applied to the patient. • Positive End-Expiratory Pressure (PEEP) valve connected to the exhalation port which maintains a constant pressure in the circuit. Each PEEP valve is rated at a certain level measured in centimeters of water (cmH2O) usually in increments of 2.5. The most commonly used levels are 5 or 7.5.

24. What are the indications for CPAP use? • CPAP is indicated for the treatment of severe respiratory distress seen in chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and to a lesser degree in asthma.

25. How does CPAP work for these conditions?

26. COPD • To understand how it works, we need to briefly review the pathophysiology of these COPD. • In COPD, the lung has lost its normal elastic recoil and the alveoli and terminal bronchioles have become stiff with scar tissue. During a COPD exacerbation, these terminal bronchioles collapse during exhalation leading to air trapping in the alveoli. This is why the COPD patient breathes through pursed lips and uses active muscle contraction to exhale. By doing so, they are keeping the pressure in the terminal bronchioles elevated to prevent their collapse.

27. CHF • In CHF, the left ventricle fails to keep up with the blood being sent to it from the lungs (preload) and/or the pressure against which it must pump (afterload). This may be the result of an unrecognized heart attack which is now decompensating, uncontrolled hypertension, valvular dysfunction, or fluid overload. Regardless, the pulmonary venous pressures rise and fluid is forced out of the pulmonary capillaries into the interstitial space between the capillaries and the alveoli. The fluid may even fill the alveoli further leading to the inability of the body to absorb oxygen and expel carbon dioxide.

28. Asthma • In asthma, there is a bronchospasm and the work of breathing is increased as the patient strives to move air in and out of the lungs. • The feature common to all three of these conditions is the increased work of breathing and the inability to effectively remove carbon dioxide from the system. As COPD, CHF, and asthma worsens, the patient’s minute ventilation (size of each breath multiplied by the breaths per minute) goes down. Less air movement results in carbon dioxide levels rising which causes a narcotic like effect on the brain further diminishing ventilatory rate. The combined effects of fatigue and rising carbon dioxide in the system leads to further lowering of the ventilatory rate and the patient suffers a respiratory arrest.

29. OK. So...how does it work? • CPAP works by "splinting" the lungs with a constant pressure of air which reduces the work of breathing. In CHF it forces the excess fluid out of the alveoli and interstitial space back into the vasculature as well as decreases venous return to the heart thereby lessening its workload. • CPAP is not as beneficial for asthma as it is for the other conditions we discussed. Fortunately, it is unlikely to hurt the patient and may help by decreasing the work of breathing. Pneumonia is another condition for which CPAP is not indicated but which may mimic the respiratory distress of COPD or CHF. However, it too is unlikely to cause any harm and may actually increase aeration of the lungs.

30. What is the major benefit of CPAP? • The major benefit of CPAP is that it provides the lung ventilatory support while you are administering the specific therapy for the condition. In essence, it buys you time to treat the COPD, CHF, or asthma before the patient arrests. This is a very important point. Once CPAP is started, it is vital that you begin administering bronchodilators to the COPD and asthma patient and nitroglycerin to the CHF patient. CPAP, by keeping the airways open and facilitating ventilation, increases the delivery of agents such as albuterol to the lung. In CHF, it decreases myocardial workload while you administer nitroglycerin to lower the blood pressure thus reducing both preload and afterload on the heart which further reduces myocardial oxygen demand.

31. What’s the bottom line? • CPAP takes the patient who is close to needing intubation and rapidly reverses their condition. Studies have proven that CPAP dramatically reduces the need for intubation which is associated with significant complications and death in these patients. • A full review of the CPAP device will be provided in the hands-on class.

32. Peripheral Intravenous Access in an External Jugular Vein

33. External Jugular • A large vein in the neck between the angle of the jaw and the middle third of the clavicle. • Connects to the subclavian vein in the central circulation. • Fluids and medications rapidly reach the core of the body.

34. External Jugular • EJ can be attempted initially in cardiac arrest. • EMT-Intermediates in the Buncombe, Madison, Yancey EMS systems may only perform EJ in patients greater than 8 years of age whom are in cardiac arrest.

35. Obtaining an External Jugular • Prepare all equipment as for peripheral IV access in an extremity. Usually a 18-14 gauge catheter is used. • Place the patient supine and/or in the Trendelenburg position. This increases blood flow to the chest and neck, thus distending the vein and making it easier to see. The supine-Trendelenburg position decreases the chance of air entering the circulatory system during cannulation

36. Place the patient in a supine or Trendelenburg position.

37. Obtaining an External Jugular • Turn the patient’s head to the side opposite of access. This maneuver makes the site easier to see and reach; do not perform it if the patient has a traumatic head and/or neck injury • Cleanse the site with antiseptics well. Use Betadine and Chloroprep if possible. Start with the site of intended puncture and work outward 1 to 2 inches in ever increasing circles.

38. Turn the patient’s head to the side opposite of access and cleanse the site.

39. Obtaining an External Jugular IV • Occlude venous return by placing a finger on the external jugular just above the clavicle. This should distend the vein, again allowing greater visualization and ease of puncture. Never apply a venous constricting band around the patient’s neck. • Position the cannula parallel with the vein, midway between the angle of the jaw and clavicle. Point the catheter at the medial third of the clavicle, bevel up.

40. Occlude venous return by placing a finger on the external jugular just above the clavicle.

41. Obtaining an External Jugular • Enter the external jugular so that the catheter is inserted from the superior head and is pointing to the inferior body. • Once “flash” has been obtain, thread the catheter into the vein as a normal peripheral IV start. • Tape the catheter as if a normal IV and place a transparent dressing over the insertion site

42. Point the catheter tip towards the clavicle and insert it, bevel up.

43. External Jugular Complications • Inadvertently puncturing the airway • Damaging the nearby arterial vessels • Unable to use in a trauma patient with a c-collar in place • Hard to occlude the vein once the needle is removed. • Fluid Overload.

44. Spinal Immobilization

45. Spinal Immobilization • If your patient does not meet the following criteria can a EMT-Intermediate Clear the C-Spine?

46. Spinal Immobilization • No - if your patient does not meet any of the previous criteria they must be placed in Spinal Immobilization. • Only a Paramedic can clear the C-Spine under state protocols

47. Spinal Immobilization • Recommended Exam: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro Consider immobilization in any patient with arthritis, cancer, or other underlying spinal or bone disease. • Significant mechanism includes high-energy events such as ejection, high falls, and abrupt deceleration crashes and may indicate the need for spinal immobilization in the absence of symptoms. • Range of motion should NOT be assessed if patient has midline spinal tenderness. • Patient's range of motion should not be assisted.

48. Spinal Immobilization • The patient should touch their chin to their chest, extend their neck (look up), and turn their head from side to side (shoulder to shoulder) without spinal process pain. • The acronym "NSAIDS" should be used to remember the steps in this protocol. • "N" = Neurologic exam. Look for focal deficits such as tingling, reduced strength, on numbness in an extremity. • S" = Significant mechanism or extremes of age. • "A" = Alertness. Is patient oriented to person, place, time, and situation? Any change to alertness with this incident? • "I" = Intoxication. Is there any indication that the person is intoxicated (impaired decision making ability)? • "D" = Distracting injury. Is there any other injury which is capable of producing significant pain in this patient? • "S" = Spinal exam. Look for point tenderness in any spinal process or spinal process tenderness with range of motion.

49. Spinal Immobilization • The decision to NOT implement spinal immobilization in a patient is the responsibility of the paramedic. • In very old and very young patients, a normal exam may not be sufficient to rule out spinal injury.