Advanced Paramedic Skills

1. Advanced Paramedic Skills Introduction to Symptom Relief

2. Quickie Overview • ACR Documentation of DMA’s • Standing Orders • Review of Symptomatology • Medications • Epinephrine • Ventolin • Glucagon • Blood Sugar Determination

3. Remember these drugs?? • Ventolin - ??? • Epinephrine??? • Glucagon • 50% Dextrose in Water (D50W)

4. Autonomic Drugs • Which are…. • Here is the mental stretching …..!!

5. How autonomic drugs work • ANS transmits nerve impulses from the CNS to the effector organs over efferent neurons (preganglionic or postganglionic) • Effector organs are the heart, smooth muscle and exocrine glands. • Neurotransmitter at effector organ determines type of neuron norepinephrine or epinephrine=adrenergic (sympathetic) acethylcholine = cholinergic (parasympathetic)

6. Receptors • If receptor responds to acethylcholine = muscarinic or nicotinic • If receptor responds to norephinephrine or epinephrine = adrenergic NOREPI EPI ACH muscarinic nicotinic adrenergic

8. Epinephrine • Adrenergic Agonist • Sympathomimetic

9. What is Anaphylaxis? • Your text definition: • An unusual or exaggerated allergic reaction to a foreign protein or other allergen, resulting in a systemic response of the body • Causes: • Environmental –such as.. • Medications –such as… • Food-such as…. • Preservatives, Dyes, Blood products etc

10. Signs and Symptoms of Anaphylaxis • - • - • - • - • - • -

11. Drug Profile • naturally occurring catecholamine that is produced in the body and released by the adrenal gland • Epinephrine can be considered the emergency hormone and norepinephrine is mainly the transmitter hormone • stimulates adrenergic neurons to bring about the various effects on the body Epinephrine

12. Pharmacokinetics • Both Alpha and Beta-receptors are stimulated by epinephrine. • Epinephrine is a “direct acting” adrenergic agonist (see explanation under Dopamine). • It is metabolized primarily by MAO (monoamine oxidase) and COMT (chol-o-methyltransferase).

13. Pharmacokinetics of Epi Cardiovascular Effects •  SVR • B/P • Electrical activity in the heart • cerebral and coronary blood flow • strength of myocardial contraction • MVO2 • automaticity

14. Receptor Response to Epi

15. Therapeutic Uses • Most widely used drug in cardiac arrest setting • refractory asthma • ANAPHYLAXIS And • severe hypotension unresponsive to dopamine • Epinephrine is used extensively in the resuscitation of children (2-10mcg) • an additive in local anaesthetic agents to help cause vasoconstriction

16. Adverse Effects • Overdose is unlikely as the drug is quickly metabolized • Increased HR/BP,Sweating • increase MVO2 demands and have to given with caution to those patients with ischemic heart disease

17. Dosage/Supplied • Adult- For anaphylacticreactions (1:1,000) 0.5mg IM/SC • 1 mg in 1 mL (1mg/ml conc) • For Cardiac arrest1:10,000 1mg IV q 3-5 mins. 2mgs ETT q 3-5 mins. • For bradycardia (hypotensive) • Pediatric- For anaphylactic reactions (1:1,000)0.1mg/10kg max 0.3mg

18. Special Prehospital Concerns • Epinephrine can be administered in via IV, ETT, SC, bolus or infusion • P1 administer it SC ONLY! • ideal dose of epinephrine • Epinephrine is light sensitive • do not add to alkaline sol’ns • For anaphylactic shock!

19. Medication Handling • 5 rights • Prepare equipment • Drawing Up epi • Prepare the site • Insert the needle • Take care of site post • Monitor patient See pages 444-448

20. Intramuscular or Subcutaneous Injection • Sites • Deltoids • Vasus lateralis Side of thigh • How to do it • 90/45 degrees • 19-23/25-27 gauge needle • 1 cc syringe

21. Salbutamol • Adrenergic agonist (beta-2) • Bronchodilator

22. Signs and Symptoms of Bronchoconstriction • Examples: • - • - • - • - • - • -

24. Drug Profile • beta agonists are thought to work is by increasing the intracellular concentrations of cAMP • causes epithelial chloride channels to open • As the chloride ions move they draw sodium ions along with them. The  in sodium ions create a gradient to draw water along with them. This  in water acts to lubricate the mucous

25. Therapeutic Uses • Ventolin is used to treat bronchospasm brought about from a number of factors. • Intrinsic vs Extrinsic Asthma, COPD • The fact that Ventolin is predominantly a beta 2 receptor stimulator, the effects on the beta 1 receptors of the heart are minimal.

26. Adverse Effects • nervousness • tremors • agitation • dizziness • palpitations • headache • tachycardia • nausea. • allergic reactions include angioedema, urticaria, bronchospasm, hypotension, rash • Overdosage may cause tachycardia, cardiac arrhythmias, hypertension, hypokalemia and in extreme cases, sudden death

27. Dosage -Adult and Pediatric Dose: Salbutamol via Nebulizer: < 25 kg – 2.5 mg >=25 kg – 5.0 mg Salbutamol via MDI < 25 1 puffs followed by 4 breaths –repeat 6 times >=25 1 puffs followed by 4 breaths –repeat 8 times • Remember to allow MDI to recharge (30secs)

28. Special PreHospital Concerns • administered by MDI (metered dose inhaler)or by nebulizer mask driven by oxygen or air. • Aerochamber is better • To test how full an MDI container is -see figure Full 1/2 Full Empty

29. How to administer Ventolin • Things to remember:

30. Glucagon Drug Profile • Pancreatic Hormone • Insulin Antagonist • Hyperglycemic Agent

31. Signs and Symptoms of Hypoglycemia • Review:

32. Therapeutic Uses • naturally occurring hormone which is produced in the alpha cells of the islets of Langerhans in the pancreas • Glucagon works in opposition to insulin as it is secreted when blood glucose concentrations decrease • increase the blood glucose concentration by causing glycogenolysis in the liver (the conversion of glycogen to glucose) as well as increasing gluconeogenesis (the production of ‘new’ glucose in the liver from amino acids).

33. Glucagon Usedfor symptomatic hypoglycemia (if unable/or not certified to establish IV access for dextrose administration). FYI As Antidote- beta blocker overdose (sinus bradycardia, hypotension, AV block as well as widening of the QRS complex, peaked T waves and ST changes) IV Glucagon reverse these by enhancing myocardial contractility, heart rate and AV conduction.

34. Special Prehospital Concerns • BG First ( <4.0 mmol) • Dose- given 1 mg SC • Contraindications • Pheochromocytoma • 0.5 mg for peds • in large amounts (phenol in sol’n) can get toxic

35. Dextrose 50% • Carbohydrate (Caloric Supplement)

36. Drug Profile • simple sugar substance that the body can rapidly metabolize while in hypoglycemic states. • It is a hypertonic solution that can produce high (intravascular) osmotic pressures, resulting in a transient rise in intravascular volume • excreted in the kidneys it results in an increased excretion of water from the body and to a lesser degree sodium and chloride • 50ml pre load contains 25 grams of dextrose Ch2OH O OH H H OH H OH OH H

37. Therapeutic Uses/Adverse Effects Adverse Effects • Hyperglycemia • severe burning in the vein • tissue necrosis if extravagation • with CVA, worsens condition due to hypertonicity Therapeutic Uses Acute hypoglycemia Hyperkalemia (helps K+ to shift intracellularly) and to prevent hypoglycemia as pt receives insulin

38. Special Prehospital Concerns • Take BS first • large vein • flush after admin • watch for aggressive behavior-hold arm • pediatrics (25% sol’n) • Thiamine first for ETOH and malnutrition

39. Blood Glucose Determination • Glucometers • How they work • Preparation of the patient • Consent • Anticipate patient changes • Prepare the glucometer • Take the blood sugar • Record the reading

40. Glucometer-Ascentia Contour • No coding • 15 sec • Touch blood to Strip • See handout

41. Blood Glucose Determination • Lab work • Heres where you get to try it on each other

42. Readings for You! -bledsoe • Review Diabetes and S&S –pg 1381-1388 • Review Anaphylaxis S& S –pgs 1394-1404 • Review bronchoconstriction- pages1181-1184 • Read Pharmacology section 414-425 and 434-448 Name a few things that could be confused with hypoglycemia! What would they present like??