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Altered Mental Status Medication Review Lung Sounds MAD Device QuickTrach Kit. February 2010 CE Advocate Condell EMS System Prepared by Sharon Hopkins, RN, BSN, EMT-P. Objectives. Upon successful completion of this module, the EMS provider will be able to:

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altered mental status medication review lung sounds mad device quicktrach kit

Altered Mental StatusMedication ReviewLung SoundsMAD DeviceQuickTrach Kit

February 2010 CE

Advocate Condell EMS System

Prepared by Sharon Hopkins, RN, BSN, EMT-P


Upon successful completion of this module, the EMS provider will be able to:

  • Describe elements of normal mental status.
  • List the components of a neurological examination in the field.
  • Describe patient assessment of a neurological examination.
  • List the three components of the Glasgow coma scale.
  • Calculate the GCS.
  • Review Region X SOP Altered Mental Status
objectives cont d
Objectives cont’d
  • Review Cincinnati Stoke Scale
  • Introduce FAST concept
  • Explain the differences between the adult and the pediatric airway.
  • Describe the assessment of the airway and respiratory system.
  • Describe the various lung sounds auscultated during assessment.
  • Discuss the methods for measuring oxygen and carbon dioxide in the blood in the prehospital setting.
objectives cont d4
Objectives cont’d
  • Identify indications, contraindications, dosing, side effects, and special considerations of Dextrose, Glucagon, Narcan, Albuterol, Epinephrine 1:1000, Benadryl, Lasix, and Morphine.
  • Describe the indications, contraindications, dosing, side effects, and special considerations for administering Narcan via the MAD tool.
  • Describe the MAD tool and the procedure for using the MAD tool.
objectives cont d5
Objectives cont’d
  • Describe indications, contraindications, complications, and the process for performing a cricothyrotomy.
  • Given a manikin, demonstrate the cricothyrotomy procedure.
  • Demonstrate medication administration with the MAD device.
normal mental status
Normal Mental Status
  • Consciousness
    • Person is fully responsive to stimuli and demonstrates awareness of the environment
  • Altered level of consciousness
    • Some form of dysfunction or interruption in the central nervous system
normal mental status7
Normal Mental Status
  • Patient is awake
  • Patient is alert – aware of surroundings
  • Patient is oriented to person, place, & time
  • Patient is cooperative
  • Patient carries on normal conversation
  • Patient able to follow/obey commands
  • Gait is even and steady
altered level of consciousness
Altered Level of Consciousness

Hallmark sign of central nervous system injury or illness

did you know
Did You Know?
  • When perfusion is declining, the first indicator is a changing level of consciousness
  • The last indicator is a falling blood pressure
assessing mental status avpu
Assessing Mental Status - AVPU
  • A – awake
  • V – responds to verbal stimuli
  • P – responds to painful stimuli
  • U- unresponsive
a awake
A – “Awake”
  • Patient is awake, alert and aware of surroundings
  • OR
  • Patient may be awake but confused
    • Report what the patient is oriented to
      • “Oriented to person but not place or time”
  • Key is watching for a change in level of consciousness from the baseline taken
v verbal response
V – Verbal Response
  • This would need to be evaluated prior to touching the “unconscious” patient
  • Problem: If trauma is involved, need to manually control the C-spine before causing the patient any movement of the c-spine
  • If possible, call the patient’s name to check for response to verbal stimuli prior to making physical contact
p painful response
P – Painful Response
  • Does not necessarily mean you have to perform a painful task to check for response
    • Start with simple tactile contact – touch
    • Add deeper stimulation if needed
      • Sternal rub
      • Pinch of thumb web space
      • Trapezius muscle squeeze (near neck)
    • Do not cause so much trauma as to leave marks/bruises
    • Observe for some kind of response with muscles
patient response
Patient Response
  • Patient response can include:
    • Opening of eyelids even briefly
    • Fluttering of eyelids
    • Wrinkling of brows
  • Most important is looking for changes in the patient’s response from one evaluation/assessment to the next
u unresponsive
U - Unresponsive
  • The patient has NO response at all
    • No moaning
    • No muscle twitch at all
      • No eyelid flutter
      • No wrinkling of the eyebrow
    • Muscles are flaccid with absolutely no response regardless of stimuli
neurological exam in the field
Neurological Exam In the Field
  • AVPU – what is level of consciousness?
  • Pupillary response
  • Movement of distal extremities
    • Wiggling fingers and toes
  • Sensation of distal extremities
    • Ability to feel contact with fingers and toes
  • GCS
    • <10 or deteriorating mental status patient is considered critical and categorized as Category I trauma
glasgow coma scale gcs
Glasgow Coma Scale - GCS
  • The best score possible is given
  • More important is watching the trend than relying on any one score
  • Objective tool
    • All using the tool on the same patient should get the same score
  • Evaluate
    • Best eye opening
    • Best verbal response
    • Best motor response
gcs eye opening
GCS – Eye Opening
  • 4 – Spontaneous; patient’s eyes are open
    • Does not have to be focusing
  • 3 – Eyes open or motion is made to verbal


    • Start with soft voice, may have to yell at patient to open eyes
  • 2 – Eyes open with tactile or painful stimuli
    • Start with gentle touch; may need to add more intense stimuli
  • 1 – No eye opening; no muscle motion at all
gcs verbal response
GCS – Verbal Response
  • 5 – Oriented to person, place, and time
  • 4 – Pleasantly confused
  • 3 – Inappropriate words
    • You can understand the word(s) spoken but they are not within context
  • 2 – Incomprehensible words – sounds
    • No intelligible word understood; moans and groans; makes noises
  • 1 – Silent; no noise is made at all
gcs motor response
GCS – Motor Response
  • 6 – Obeys commands
  • 5 – Localizes pain / purposeful movement
    • Can push you away or grab at the noxious stimuli (IV, collar, bandaging, your hands)
  • 4 – Withdrawal
    • No longer localizing, just withdraws/pulls away to get away from annoying/painful stimuli (IV, collar, bandaging, your hands)
motor cont d
Motor cont’d
  • 3 – Flexion to pain
    • Arms flex/bend slowly toward center of chest when any stimuli applied
  • 2 – Extension to pain
    • Arms slowly extend and curl inward and legs straighten when any stimuli applied
  • 1 – No movement at all
gcs results
GCS Results
  • Score range 3 – 15
  • Minor head injury – 13 – 15
  • Moderate head injury – 9 – 12
  • Severe head injury (coma) - <8
    • Significant mortality risk
    • Consider intubation or other means to secure the airway
gcs practice
GCS Practice
  • Read the following case scenarios
  • Determine the best eye opening, verbal response, motor response
  • When the response is asymmetrical, award the highest points possible
  • Don’t guess or assume what you think they really can do
  • Award points for what is performed
  • Be objective
gcs case 1
GCS Case #1
  • Patient lying in the bed (no trauma), eyes are closed
  • You need to yell the patient’s name and then the eyelids flicker
  • They are mumbling
  • They are grabbing at your hands and pushing you away. They have pulled out the IV.
gcs case 1 score
GCS Case #1 Score
  • Eye opening – 3
    • Responded to loud voice
  • Verbal response – 2
    • Mumbling is incomprehensible words/sounds
  • Motor response – 5
    • Patient can recognize (localize) what feels obnoxious and what he wants to stop so they are grabbing at you and pulling at equipment
  • Total GCS - 10
gcs case 2
GCS Case #2
  • Patient is lying in the street watching you approach
  • They mumble as you talk to them
  • They are grabbing at your hands and pushing you away
gcs case 2 score
GCS Case #2 Score
  • Eye opening – 4
    • Spontaneous; doesn’t necessarily indicate focusing
  • Verbal response – 2
    • Mumbling, moaning, groaning
  • Motor response – 5
    • Purposeful movement by grabbing at what the patient perceives as noxious stimuli
  • Total GCS - 11
gcs case 3
GCS Case #3
  • Patient watches your approach and acknowledges your presence
  • Patient answers most questions and thinks you are their nephews come to visit
  • Patient able to move left arm to command but not able to move right arm (new onset – possible stroke)
gcs case 3 score
GCS Case #3 Score
  • Eye opening – 4
    • Spontaneous
  • Verbal response – 4
    • Pleasantly confused
  • Motor response – 6
    • Highest possible score based on the arm that can and does move
  • Total GCS - 14
gcs case 4
GCS Case #4
  • Child’s eyelids flicker when deformed extremity is manipulated
  • Child moans out when painful areas are manipulated
  • Child pulls away when touched and tries to turn away from EMS
gcs case 4 score
GCS Case #4 Score
  • Eye opening – 2
    • Response to painful stimuli
  • Verbal response – 2
    • Moans and groans are incomprehensible words / sounds
  • Motor response – 4
    • Withdrawing from what is sensed as painful stimuli
    • Flexion would be slow flexing of arms toward center of chest – this patient’s response is not flexion
  • Total GCS – 8 (Protect airway; consider intubation)
gcs case 5
GCS Case #5
  • Patient’s eyes remain closed; no eyelid movement at all
  • There are no sounds heard from the patient
  • The patient straightens their arms, twists their wrists, arches their back, and straightens their legs when stimulated
gcs case 5 score
GCS Case #5 Score
  • Eye opening – 1 (no response)
  • Verbal response – 1 (no response)
  • Motor response – 2
    • Abnormal extension
    • The worse level of response prior to no response at all
  • Total GCS – 4
    • Patient is critical; Category I
    • Patient usually needs some airway intervention
common causes of altered mental status
Common Causes of Altered Mental Status
  • A – acidosis, alcohol
  • E – Epilepsy
  • I – Infection (brain, sepsis)
  • O – Overdose
  • U – Uremia (kidney failure)
  • T – Trauma, tumor, toxins
  • I – Insulin – hypo or hyperglycemia
  • P – Psychosis, poison
  • S – Stroke, seizure
initial patient assessment
Initial Patient Assessment
  • Airway
    • Open or obstructed
    • Maneuvers needed to open
      • Head tilt / chin lift
      • With trauma, modified jaw thrust
  • Breathing
    • Quality
    • Quantity (eyeball assessment at this time)
initial assessment cont d
Initial Assessment cont’d
  • Circulation
    • Quality
    • Quantity (don’t count; get estimate of range)
  • Disability – need to obtain baselines
    • AVPU
    • GCS
  • Expose to examine
    • Can’t evaluate or fix what you can’t see
assessment tools
Assessment Tools
  • AVPU
    • Alert (interpreted as an awake patient)
    • Responds to verbal stimuli
    • Responds to painful stimuli
    • Unresponsive
assessment tools38
Assessment Tools
  • GCS
    • Best eye opening response
    • Best verbal response
    • Best motor response
  • Scores range from the lowest of 3 to highest of 15
  • Obtain and document GCS on all patient calls
cincinnati stroke scale
Cincinnati Stroke Scale
  • Obtain for suspicion of TIA or stroke
  • Evaluate for facial droop
    • Check the patient’s symmetry during a broad, big smile (teeth showing)
  • Evaluate for arm drift
    • Check for weakness in holding arms outstretched, palms up, for 10 seconds
  • Evaluate for clear speech
    • Have patient repeat words listening for clear speech patterns
airway protection and the stroke patient
Airway Protection and the Stroke Patient
  • Crucial - high mortality rate for aspiration
  • Is airway patent and can patient protect their own airway?
    • Check if patient is able to handle & swallow own saliva
      • Detailed/involved swallow study done in-hospital
    • Patient speaks in clear unobstructed voice
  • Interventions to consider
    • Have suction on and ready
    • Ability to quickly turn patient onto their side
fast public educational tool
FAST - Public Educational Tool
  • Tool developed by organizations for public recognition of stroke and to encourage FAST action
region x sop altered mental status
Region X SOP – Altered Mental Status
  • Consider etiology
    • If cause of problem can be identified, then interventions can be focused
      • Diabetes – check blood sugar
      • Drug overdose – what are the environmental clues
      • Poisoning – environmental evidence around
      • Alcohol related – environmental evidence; use your nose
sop altered mental status
SOP – Altered Mental Status
  • Maintain airway
    • Patency extremely important
  • Evaluate rate and quality
    • If respirations inadequate, ventilate
      • 1 breath every 5-6 seconds all patients – infancy to elderly
  • Intubate as necessary
  • Use C-spine precautions as indicated
    • If any doubt, err on side of extra precautions
  • Provide Routine Medical Care
    • IV – O2 - monitor
sop altered mental status44
SOP – Altered Mental Status
  • Obtain blood glucose level
    • If <60 – treat
      • Adult - Dextrose 50% 50 ml IVP
      • Child 1 – 15 – Dextrose 25% 2 ml/kg
      • Infant <1 – Dextrose 12.5% 4 ml/kg
        • Dilute 1:1 ratio D 25% with normal saline
        • Equal amounts of product make 1:1 dilution (Dextrose and normal saline)
treating altered mental status
Treating Altered Mental Status
  • In absence of IV access
    • Adult – Glucagon 1 unit (1 ml) IM
    • Pediatrics < 15 – Glucagon 0.1 mg/kg IM
      • Max dose of 1 mg
  • Practice: 44 pound child – no IV access
    • How many kg?
      • 44  2.2 = 20 kg
    • 20 x 0.1 = 2 mg
    • How much Glucagon do you give?
      • Max of 1 mg
altered mental status cont d
Altered Mental Status cont’d
  • If patient not alert, respirations decreased, or narcotic overdose suspected:
    • Narcan 2mg IN/IVP/IO
      • Repeat every 5 minutes as needed until desired effect
        • Quality of respirations have improved
        • Don’t need patient to be 15 on GCS
        • Don’t need patient awake necessarily
      • Maximum total dose 10 mg
  • Transport
altered mental status cont d47
Altered Mental Status cont’d
  • Note:
    • Attempt to identify substances involved
    • If not a safety hazard, obtain and transport substance container with the patient
    • Consider use of restraints prior to administration of Narcan
      • Patient may become violent when level of consciousness improves
Adult Airway Pediatric airway
  • Note funnel shaping of pediatric airway
notice difference in tongue size
Notice Difference in Tongue Size
  • Adult airway
  • Pediatric airway


pediatric airway differences
Pediatric airway Differences
  • Jaw smaller
  • Teeth softer and more fragile
  • Tongue relatively larger
    • Potential to produce more obstruction
  • Epilgottis floppier and rounder
    • Recommend straight Miller blade over curved Macintosh for intubation
  • Larynx more superior & anterior
    • Higher and more forward
    • Funnel shaped due to underdeveloped cricoid cartilage
      • Under age 10 cricoid cartilage narrowest part of airway
  • Ribs and cartilage softer and more pliable
    • Children rely on diaphragm muscle for breathing
airway assessment
Airway Assessment
  • Inspection
    • Begin as you are approaching the patient
  • Auscultation
    • Listen for audible sounds, then use stethoscope
  • Palpation
    • Can gather a lot of information through the art of touch
assessment of airway
Assessment of Airway
  • Initial assessment
    • ABC’s
      • Airway open?
        • Fully open with adequate air exchange?
        • Partially or fully obstructed with poor air exchange?
      • Are they breathing?
        • Look for chest rise and fall
        • Listen for air movement
        • Feel for air movement
      • Do they have a pulse?
airway assessment cont d
Airway Assessment cont’d
  • Inspection
    • Evaluate adequacy of breathing
    • Note any signs of trauma
    • Assess skin color
      • Paleness and diaphoresis due to sympathetic stimulation in early respiratory compromise
      • Cyanosis if deoxygenated (LATE SIGN!!!)
    • Patient positioning
      • Tripod – leaning forward (CHF? Asthma?)
      • Orthopnea – can’t lay down (CHF? Asthma?)
inspection cont d
Inspection cont’d
  • Observe for dyspnea
    • May cause or be caused by hypoxia
    • Prolonged dyspnea can lead to anoxia (absence of oxygen)
    • Is dyspnea a new onset or perhaps chronic in the patient with long standing COPD
abnormal respiratory patterns
Abnormal Respiratory Patterns
  • Kussmaul’s
    • Deep, slow or rapid, gasping breathing
    • Commonly found in diabetic ketoacidosis in attempt to blow off excess CO2 (acid)
  • Cheyne –Stokes
    • Progressively deeper, faster breathing alternating with gradually shallow and slower breathing
    • Indicates brainstem injury
respiratory patterns cont d
Respiratory Patterns cont’d
  • Biot’s
    • Irregular pattern of rate and depth with sudden, periodic episodes of apnea
    • Indicates increased intracranial pressure
  • Central neurogenic hyperventilation
    • Deep, rapid respirations
    • Indicates increased intracranial pressure
  • Agonal
    • Shallow, slow, or infrequent breathing
    • Indicates brain anoxia, impending death
respiratory assessment cont d
Respiratory Assessment cont’d
  • Auscultation
    • Listen 1st audibly for any abnormal sounds
    • Have patient cough to clear loose secretions
    • Then listen with stethoscope
      • Right and left apex (under clavicles)
      • Right and left bases (8th – 9th intercostal space, midclavicular)
      • Right and left lower thoracic back or right and left midaxillary line (lateral chest wall)
auscultation cont d
Auscultation cont’d
  • Posterior aspect preferable to anterior surface
    • Less tissue mass
    • Lungs closer to the surface
    • Less interference with heart sounds
  • Anterior and lateral sections of the chest are more accessible especially in supine patients
  • Evaluate for symmetrical equality
  • Keep stethoscope in place long enough to hear end of exhalation
    • Many abnormal sounds heard first at end of exhalation
abnormal lung sounds
Abnormal Lung Sounds
  • Snoring
    • Partial obstruction of upper airway, usually from tongue
    • Patient needs airway repositioned
  • Gurgling
    • Accumulation of fluids (blood, vomitus, other secretions) in upper airway
  • Stridor
    • Harsh, high-pitched sound heard on inhalation; usually indicates laryngeal edema or constriction
lung sounds cont d
Lung Sounds cont’d
  • Wheezing
    • Musical, squeaking, or whistling sound heard in inspiration and/or exhalation
    • Indicates bronchiolar constriction
      • Asthma, COPD
  • Quiet
    • Diminished or absent breath sounds ominous
    • Indicates serious problem with airway, breathing, or both
lung sounds cont d61
Lung Sounds cont’d
  • Crackles (rales)
    • Fine, bubbling sound heard on inspiration
    • Indicates fluid in smaller airways
      • CHF
      • Pneumonia
    • Gas exchange may be compromised
  • Rhonchi
    • Course, rattling noise heard on inspiration
    • Associated with inflammation, mucus, or fluid in bronchioles
    • Gas exchange may be compromised
      • Chronic bronchitis
airway assessment62
Airway Assessment
  • Palpation
    • Often forgotten assessment tool
    • Palpate chest wall for
      • Tenderness
      • Symmetry
      • Abnormal motion
      • Crepitus (bone crunching)
      • Subcutaneous emphysema
        • Air leakage into tissue
pulse oximetry
Pulse Oximetry
  • Measures hemoglobin oxygen saturation in peripheral tissue
  • Non-invasive means to measure effectiveness of oxygenation and ventilation
  • Continually reflects changes
    • May detect changes faster than assessment of vital signs
pulse oximetry64
Pulse Oximetry
  • Place probe over a peripheral capillary bed
    • Fingertip, toe, earlobe
  • 2 sensors take measurements of light reaching them from 2 light emitting diodes
    • Oximeter calculates ratio of light received
      • Influenced by amount of oxygenated versus deoxygenated hemoglobin
    • SpO2 determined
spo 2 results
SpO2 Results
  • 95 – 99% - normal
  • 91 -94% - mild hypoxia
    • Perform additional evaluation
    • Administer supplemental oxygen
  • 86 – 91% - moderate hypoxia
    • Perform additional evaluation
    • Administer 100% supplemental oxygen
  • <85% - severe hypoxia
    • Immediate intervention required
spo 2 error results
SpO2 Error Results
  • Current equipment more accurate; less error readings
  • False readings possible
    • Carbon monoxide exposure – false high
    • High-intensity lighting near sensors
    • Hemoglobin abnormalities
    • Absent peripheral pulses
    • Hypovolemia; severe anemia
      • SpO2 may be normal but the amount of hemoglobin available is low
  • Coordinate readings with patient assessment
  • Graphic recording or display of measurement of expired CO2 over time
  • End-tidal CO2 (ETCO2) – measurement of CO2 concentration at end of expiration
  • Provides information
    • Systemic metabolism (production of CO2)
    • Circulation
    • Ventilation
how does co 2 circulate
How Does CO2 Circulate?
  • CO2 is normal end product of metabolism
  • Transported by venous system to right side of heart
  • Pumped from right ventricle  pulmonary artery  lungs and pulmonary capillaries
  • Diffuses into alveoli
  • Removed from body via exhalation
poor perfusion states
Poor Perfusion States
  • Shock, cardiac arrest, pulmonary embolism, bronchospasm, incomplete airway obstruction (ie: mucous plugging)
    • Perfusion decreased
    • ETCO2 will reflect pulmonary blood flow and cardiac output
    • Will not reflect ventilation in poor perfusion states
end tidal co 2 detector
End Tidal CO2 Detector
  • Contains pH sensitive chemically impregnated paper to estimate ETCO2 level
  • Color change is reversible
  • Will reflect changes breath to breath
  • Paper will be unreliable if contaminated with acidic drugs or gastric contents
interpreting the etco 2
Interpreting the ETCO2
  • Yellow – indicates measured CO2 being exhaled
    • Evaluate after 6 breaths
  • Tan – low levels of CO2 measured
    • Misplaced tube or poor carbon dioxide production
      • Evaluate tube positioning
      • Evaluate patient perfusion
  • Blue or purple – no CO2 being measured
    • Suspect unsuccessful intubation
etco 2
  • Applications
    • Verify placement of endotracheal tube
    • Assess effectiveness of CPR
      • CO2 levels fall abruptly at onset of cardiac arrest
      • CO2 levels begin to rise with effective CPR
Medication Review




Side effects

Special considerations

  • Carbohydrate used to raise the sugar level
  • No contraindication in suspected hypoglycemia
  • Administered when the blood sugar level is less than 60
  • Dose based on age
    • Adult 16 and over – 50% 50 ml slow IVP
    • 1 – 15 – D 25% - 2 ml / kg slow IVP
    • <1 – D 12.5% - 4 ml / kg slow IVP
      • Mix 1:1 dilution with D25% and normal saline
dextrose cont d
Dextrose cont’d
  • Local vein irritation may occur especially when small veins are used
  • If glucagon was administered and then an IV site is secured, retest the blood sugar level
    • If blood glucose remains <60 and patient condition not improved, administer Dextrose
  • Hormone to stimulate breakdown of glycogen (stored form of glucose)
  • Patient may have an allergic reaction if they have allergies to proteins
  • Adult dosing – 1 mg (1 unit) IM
  • Pediatric dosing up to 15 years old – 0.1 mg/kg (max dose 1 mg – 1 unit)
glucagon cont d
Glucagon cont’d
  • Observe for nausea and vomiting
  • May take up to 20 minutes for Glucagon to be effective
  • Will not have any effect if there are no stores of glycogen in the liver
  • Patient requires rapid transport and continued efforts at IV access
  • Drug must be reconstituted prior to administration
  • Ventolin, Proventil
  • Bronchodilator with onset 5 – 15 minutes after inhalation
  • Used in asthma, to reverse bronchospasm in COPD, and bronchospasm & laryngeal edema of an allergic reaction
  • All patients inhale 2.5 mg via nebulizer
albuterol cont d
Albuterol cont’d
  • May cause tachycardia & restlessness
  • Has greater influence in the lungs than on the heart
  • Less effective if patient taking beta blockers at home (usually for hypertension; meds end in “alol”)
    • Beta blockers block bronchodilation response
  • Offer aerosol mask if patient unable to keep mouthpiece sealed between lips
albuterol kit and masks
Albuterol Kit and Masks
  • Watch for signs of exhaustion
  • May need to be bagged


to O2


2.5 mg / 3 ml

Available in

adult and

pediatric sizes

epinephrine via nebulizer
Epinephrine via Nebulizer
  • In presence of croup/epiglottits
    • If patient not responding to 2 doses of Albuterol, provide alternate treatment
      • Epinephrine 1:1000 1 ml mixed with 2 ml normal saline
      • Mix in nebulizer
      • Connect to oxygen to create a mist
      • Assist patient while inhaling the mist
    • Nebulized Epinephrine for moderate to severe cases
epinephrine 1 1000
Epinephrine 1:1000
  • A drug that mimics the sympathetic nervous system
    • Stimulation on the vessels trigger vasoconstriction
      • Will raise the blood pressure
    • Stimulation in the lungs triggers bronchodilation
      • Will improve air exchange
  • Useful in asthma, COPD, allergic reactions with airway involvement, and anaphylaxis
epinephrine 1 1000 cont d
Epinephrine 1:1000 cont’d
  • Use with caution in the elderly and those with heart disease
    • Can strain the heart by increasing the workload of the heart (rate and force of contractions)
  • Adult dosing allergic reaction with airway involvement – 0.3 mg SQ
  • Adult dosing anaphylaxis – 0.5 mg IM
    • Faster absorption in poor perfusion
epinephrine 1 1000 cont d84
Epinephrine 1:1000 cont’d
  • Pediatric dosing up to 15 years of age
    • Allergic reaction with airway involvement
      • Epi 1:1000 - 0.01 mg/kg SQ
      • Max single dose 0.3 ml (0.3 mg)
      • May repeat every 15 minutes
    • Anaphylaxis
      • Epi 1:1000 – 0.01 mg/kg IM
      • Max single dose 0.3 ml (0.3 mg)
      • IM faster absorption in poor perfusion state
      • May repeat every 15 minutes
epinephrine 1 1000 cont d85
Epinephrine 1:1000 cont’d
  • May cause:
    • Tachyarrhythmias
    • Palpitations
    • Restlessness
    • Anxiety
    • Headache
  • May increase oxygen demand in the heart
    • Use cautiously in elderly and those with heart disease
benadryl diphenhydramine
Benadryl - Diphenhydramine
  • Antihistamine to block the release of histamine in allergic reactions
  • Max effect in 1 – 3 hours
  • Duration of effect 6 -12 hours
    • Medication must be continued over several days or symptoms will rebound
  • Useful in allergic reactions including anaphylaxis
benadryl cont d
Benadryl cont’d
  • Avoid use in severe, uncontrolled asthma and COPD
  • Adult dosing
    • Stable allergic reaction – 25 mg slow IVP or IM
    • Allergic reaction with airway involvement & anaphylaxis – 50 mg slow IVP or IM
  • Pediatric dosing – 1 mg/kg IVP
    • Stable allergic reaction – max dose 25 mg
    • Allergic reaction with airway involvement or anaphylaxis – max dose 50 mg
benadryl cont d88
Benadryl cont’d
  • May cause drowsiness, headache, confusion, wheezing, palpitations, hypotension, nausea, vomiting, drying of secretions
  • Elderly particularly sensitive to effects of Benadryl
    • Watch for hypotension and drowsiness
lasix furosemide
Lasix (furosemide)
  • Diuretic that stops reabsorption of sodium and chloride in the kidneys
  • Triggers dilation of the venous system
    • Could drop blood pressure
    • Decreases pre-load
      • Amount of blood returning to the heart
  • Onset of venodilation immediate
  • Onset of diuretic effect within 15 – 20 minutes
lasix furosemide cont d
Lasix (furosemide) cont’d
  • Useful in CHF and pulmonary edema
    • Venodilation useful in hypertensive crisis
  • Slight risk in persons allergic to sulfa drugs (typically antibiotics)
  • Dosing is 40 mg IVP/IO
    • If patient is on Lasix, they are sensitized to it
    • Use the larger dose of 80 mg IVP/IO
lasix furosemide cont d91
Lasix (furosemide) cont’d
  • May cause headache, dizziness, hypovolemia, nausea
  • Patient may experience temporary hearing loss and ringing in the ears with repeated doses given rapid IVP/IO over a period of time
  • Narcotic analgesic (opioid)
    • Reduces anxiety
    • Creates a euphoric feeling
    • Depresses the central nervous system (CNS)
      • Reduces pain sensation
    • Dilates venous blood vessels
      • Decreases blood return to the heart (pre-load)
  • Useful in ACS, pulmonary edema, pain
  • Potentiates versed during conscious sedation
    • Helps versed to be more effective
morphine cont d
Morphine cont’d
  • Dosing
    • 2 mg given slow IVP (over 2 minutes)
    • May repeat every 2-3 minutes
    • Maximum total dose is 10 mg
  • Side effects
    • Hypotension
    • Respiratory depression
    • Bradycardia
    • Altered level of consciousness
morphine cont d94
Morphine cont’d
  • Opioids cause pupils to constrict
  • Use cautiously when other depressant drugs have been taken
    • Includes alcohol
  • Reversal agent is Narcan
    • Adult dosing 2 mg IVP
      • May repeat every 5 minutes; max total 10 mg
    • Pediatric dosing < 20kg – 0.1 mg/kg IVP/IO/IM
      • Max total dose is 2mg
      • > 20kg – 2 mg IVP/IO/IM
  • Narcotic antagonist with an onset within 2 minutes
  • May cause withdrawal symptoms including seizures
  • Adult dose – 2 mg IN/IVP/IO
    • Repeated every 5 minutes as needed up to 10 mg
  • Pediatric dose up to 15 years weight based
    • <20 kg (44#) – 0.1 mg/kg IVP/IO/IM
    • >20 kg (44# - typically a 4-6 year old) – 2 mg IVP/IO/IM
narcan cont d
Narcan cont’d
  • Side effects are rare. Watch for hypotension, nausea, vomiting, blurred vision, opiate withdrawal (including seizures)
  • Goal is to reverse severe respiratory depression; NOT to have an awake & talking patient
  • Duration of Narcan may be shorter than drug it is trying to counteract
    • Watch for return of symptoms
medication delivery mad
Medication Delivery - MAD
  • Mucosal atomization device
  • Tool to deliver medications via nasal route
    • Medication atomized into tiny particles
    • Nasal mucosa highly vascular
      • Immediate absorption into bloodstream
      • Onset of action within 3-5 minutes
      • Peak onset 15-20 minutes
using nasal route
Using Nasal Route
  • Unable to establish IV access
  • Medication administration indicated
  • Nasal mucosa intact and clear of blood and mucus
  • Luer tip can be connected to variety of sizes of syringe
  • White wedge fits firmly into nostril
  • Fine mist spray covers a large surface area
  • Medication adheres to nasal mucosa versus running down the throat
  • Each nostril can tolerate up to 1 ml volume
    • Narcan packaged 2mg/2ml – will need to deliver 1 ml in each nostril
preparing the syringe
Preparing the Syringe
  • Variety of ways to prepare the syringe with the MAD tip
  • Goal is to deliver a maximum of 1 ml of volume per nares
  • Acceptable to use one syringe and deliver half the dose into one nares, then place the same MAD tip into the 2nd nares and deliver the remaining dose from the one syringe
  • Can prepare 2 equal, separate syringes
drawing up medication from a vial
Drawing Up Medication From a Vial
  • Aspirate drug into syringe
    • Draw up volume of medication
    • You can add extra 0.1 ml volume to account for the dead space when delivering the medication into one nostril
  • Disconnect the syringe from the needle
using a prefilled syringe
Using a Prefilled Syringe
  • Prepare the prefilled syringe
    • Expel excess air
    • Check for accuracy of volume
      • Consider keeping 0.2 ml of excess volume to account for the dead space for each nostril (when using one syringe for both nostrils)
attach mad tip to syringe
Attach MAD Tip to Syringe
  • Suction nasal cavity as needed to clear blood or secretions
    • Clear nasal passages enhance absorption of medication
  • Deliver medication in divided doses
    • Maximum of 1 ml per nares
inserting mad nasal
Inserting MAD Nasal
  • Control the patients head with one hand
    • Need to prevent movement
  • Gently but firmly place the MAD nasal into one nostril
    • Aim upward and toward ear on same side
  • Briskly compress the syringe to deliver the drug as an atomized mist into nares
dispensing mist
Dispensing Mist
  • Must briskly compress syringe to convert liquid drug to a fine atomized mist
    • Mist results in broader mucosal coverage; better chance of absorption into the blood stream than drops that can run straight back into the throat.
  • Region X will implement the MAD beginning with Narcan
  • Implementing MAD begins at the completion of the 3rd day of department training
  • Document “IN” for route of administration
  • Will have the potential in the future to add further medication using the MAD
cricothyrotomy quicktrach
Cricothyrotomy, QuickTrach
  • Indications
    • Assisted ventilations required and all other means have failed to secure an airway
  • Contraindications
    • Transected trachea
    • Less invasive maneuver will be effective
  • BVM
  • QuickTrach kit
    • >77 pounds use 4 mm kit
    • 22 – 77 pounds use 2 mm kit
    • < 22 pounds use needle cricothyrotomy
  • Skin prep material
quicktrach kit contents
QuickTrach Kit Contents
  • Needle with syringe
  • Cannula with wings for strap attachment
  • Extension tubing
  • Velcro strap
quicktrach cont d
QuickTrach cont’d
  • Procedure
    • Assemble equipment
    • Patient supine, neck hyperextended if no trauma
    • Locate cricothyroid membrane and cleanse site
      • Soft spot palpated just below Adam’s apple
      • Or, start at notch, run fingers up toward head
        • First ridge of bone palpated is cricoid cartilage
        • Membrane is just above this bony cartilage
procedure cont d
Procedure cont’d
  • Anchor and stretch skin slightly
  • Puncture cricothyroid membrane at 900 angle
  • Aspirate syringe as needle enters trachea to confirm placement
    • Ability to freely aspirate air
  • Change angle of needle to 600 towards feet
  • Advance device until stopper is flush with skin
  • Remove stopper
    • Stopper will be snug; avoid motion of needle
  • Slide plastic cannula forward until snug against skin as you remove needle and syringe
    • Advance cannula as you remove needle like starting an IV
procedure cont d112
Procedure cont’d
  • Hold cannula snuggly
    • Patient may reflexively cough and could dislodge cannula
  • Attach flexible connecting tube to cannula proximal end
  • Begin to bag/ventilate the patient immediately
    • Once every 6-8 seconds for all patients
  • Confirm placement
    • Auscultation lung sounds
    • Adequate chest rise
  • Finish securing cannula with neck strap
case study 1
Case Study #1
  • Your patient called 911 after dropping her tea cup and being unable to move her right side
  • Conscious, cooperative, speech slurred
  • VS: 175/110; P – 98; R – 18; pupils cataract
  • Initial care started (IV – O2 – monitor)
  • What is your impression?
  • What specific assessment should be done?
case study 1 cont d
Case Study #1 cont’d
  • Impression
    • Acute stroke
  • Additional assessment
    • Cincinnati Stroke Scale
      • Facial droop
      • Arm drift
      • Speech
  • Transport decision
    • Is CT scan available at receiving hospital?


case study 2
Case Study #2
  • You have arrived at a local school for a patient with asthma
  • Assessment taken walking towards child
    • Sitting upright
    • In obvious distress
      • Use of accessory muscles – neck, intercostal
      • Increased respiratory rate
      • Panic on their face
    • Impression
      • Severe acute asthma attack
  • Is your assessment done after vital signs?
case study 2 cont d
Case Study #2 cont’d
  • Assessment performed
    • Observation / visual inspection
    • Initial ABC’s
      • To determine presence of life threats
    • Auscultate breath sounds
      • Bilateral wheezing heard predominately on exhalation
    • Obtain vital signs
      • 98/62; P – 110; R – 28 and labored; SpO2 94%
case study 2 cont d117
Case Study #2 cont’d
  • Interventions required
    • IV – O2 – monitor - medication
  • Question
    • Do you need an IV established prior to administration of medication?
      • No, albuterol nebulizer should be started as soon as possible
      • Give verbal prompts to slow breathing down, to take deeper breaths, and to eventually take and hold a deep breath
case study 3
Case Study #3
  • You are on the scene of a traumatically injured patient
  • When asking them to open their eyes, you yelled their name and their eye opened briefly and then closed again
  • They are using swear words during care provided
  • They are pulling off equipment and grabbing at your hands while you provide care
  • What is their GCS?
case study 3 cont d
Case Study #3 cont’d
  • Eye opening
    • To verbal – 3 points
  • Verbal response
    • Inappropriate words – 3 points
  • Motor response
    • Purposeful movement – 5 points
  • Total GCS – 11 points
    • Indicates moderate head injury
case study 4
Case Study #4
  • You have arrived on the scene for a patient complaining of dyspnea
  • Your patient is 62 years old
  • They are sitting in the tripod position
  • They are using accessory muscles and have an increased respiratory rate
  • With your stethoscope, you auscultate crackling sounds heard in the bases during exhalation
case study 4 cont d
Case Study #4 cont’d
  • What are these breath sounds?
    • Crackles
  • What do these breath sounds indicate?
    • Fluid in the smaller airways
      • CHF, pulmonary edema, pneumonia
  • What medications may be indicated if CHF?
    • Nitroglycerin – venodilator
    • Lasix – venodilator and diuretic
    • Morphine – venodilator, reduce anxiety
    • And of course, oxygen
  • Intervention to add is CPAP
case study 5
Case Study #5
  • You received a 911 call for a local school with a 7 year old student with an asthma attack
  • Your impression is an acute asthma attack
  • You begin supplemental oxygen and begin to prepare to provide interventions
case study 5 cont d
Case Study #5 cont’d
  • If this is an asthma attack, what signs and symptoms do you expect?
    • Sitting up leaning forward
    • Dyspnea with shortness of breath
    • Increased respiratory rate
    • Use of accessory muscles
    • Dry mucous membranes
    • Possibly audible wheezing
    • Bilateral wheezing heard first on exhalation
    • Dry, nonproductive cough
case study 5 cont d124
Case Study #5 cont’d
  • If you cannot hear any breath sounds, what does this mean?
    • The airway is so constricted that no air is moving in or out – ominous
  • What does wheezing sound like?
    • Whistling, musical sound that can be heard on inhalation and exhalation
      • The louder the breath sounds the more air that is exchanging
case study 5 cont d125
Case Study #5 cont’d
  • What medication is indicated?
    • Albuterol 2.5 mg (in 3 ml) nebulizer
  • How do you administer the treatment?
    • Calmly, quietly talk the patient through breathing
    • Get the patient to slow down the breathing
    • Get the patient to take some deeper breaths
    • Get the patient to inhale and hold their breath periodically to get the drug into the lungs
case study 6
Case Study #6
  • You have arrived on the scene for an unresponsive male in his twenties
  • The patient responds to painful stimuli
  • The respirations are 6 per minute and shallow
  • Pupils are constricted
  • What is your impression?
  • What interventions are necessary?
case study 6127
Case Study #6
  • Impression
    • Narcotic overdose
  • Interventions
    • Immediately support ventilations
      • Bag at a rate of once every 5-6 seconds
    • Protect the airway from aspiration
    • Administer Narcan 2 mg IN
      • Administer a maximum of 1 ml per nares
case study 7
Case Study #7
  • You are unable to ventilate a patient via BVM
  • What options are available?
    • Reposition the airway
      • Consider c-spine precautions if indicated
    • Attempt intubation
    • QuickTrach if unable to intubate
    • Needle cricothyrotomy if unable to identify landmarks
case study 7129
Case Study #7
  • Landmarks
    • Soft space just inferior/below thyroid cartilage (Adam’s apple)


    • Start in notch and move finger upward
      • Feel first bony prominence – cricoid cartilage
      • Palpate for soft space above the cricoid cartilage
  • Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles and Practices. Prentice Hall. 2009.
  • Campbell, J. BTLS 5th Edition. Brady. 2004.
  • Region X SOP, March 2007; amended January 1, 2008.