simcoe paramedic services cme 2010 n.
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Simcoe Paramedic Services CME 2010. Agenda. Didactic: STEMI update TOR King LT Anaphylaxis Skills Neonatal Resuscitation Cardiac arrest & KING LT Breath sounds IM injection IV start, fluid and dextrose administration Scenarios KAT. General Housekeeping.

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Simcoe Paramedic Services CME 2010

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Presentation Transcript
  • Didactic:
    • STEMI update
    • TOR
    • King LT
    • Anaphylaxis
  • Skills
    • Neonatal Resuscitation
    • Cardiac arrest & KING LT
    • Breath sounds
    • IM injection
    • IV start, fluid and dextrose administration
  • Scenarios
  • KAT
general housekeeping
General Housekeeping
  • Did your name, address, telephone, cell phone or email change since the last CME?
  • If so please fill out a medic info sheet!


auditing housekeeping
Auditing Housekeeping
  • Please ensure the use of
    • 010 Vital signs code.
  • Document Vital signs pre and post each medication administration on the ACR, not as a group at the bottom of the ACR
  • Do not use a procedure code (i.e. 615 NTG) when you are ruling out NTG administration. Use 030 ALS assessment
what do i attach to the acr
What do I attach to the ACR?

From the LP15 printouts:

  • Vital sign log
  • ECG with O2Sat waveform (Plethysmograph)
  • All 12 Lead ECG’s with patients name recorded on each ECG.
simcoe stemi bypass project1
Simcoe STEMI Bypass Project
  • 50 patients
    • 6 bypassed without meeting criteria
      • 1 paced
      • 1 Aflutter with ST elevation
      • 1 BH MD bypass
      • 3 CP/symptom onset time criteria
simcoe stemi bypass project2
Simcoe STEMI Bypass Project
  • Protocol < 60 minutes from patient contact to Southlake
  • Strict protocol regarding patient hemodynamic stability
  • Median transport time = 57 minutes
  • No adverse events
simcoe stemi bypass project3
Simcoe STEMI Bypass Project
  • Summary
    • Meeting timeframe goals
    • Southlake/SOCPC Steering Committee monitoring each bypass and modifying protocol to optimize system
    • Patient safety maintained
Likely to be older (74 v 67)

Women (49% v 38%)

Diabetic (33% v 25%)

Prior heart failure (26% v 12%)

Longer delay to assessment (8% v 5%)

Less likely to be diagnosed (22% v 50%)

Less likely to receive treatment (25% v 74%)

Most likely to die (23% v 9%)

Patient Presentation

33% of patients with confirmed MI present with S & S other than chest discomfort. This group compared with those that present with chest discomfort are:

pre hospital 12 lead
Pre-Hospital 12 Lead
  • Perform a history and physical exam
  • Patients ≥40 kg with signs and symptoms of cardiac ischemia you must acquire a 12 lead ECG
    • LP15 software will interpret findings
      • STEMI positive ECG

*** Meets ST Elevation MI Criteria****

      • STEMI negative ECG All other statements
12 lead ecg acquisition
12 Lead ECG acquisition
  • Must be performed on all patients presenting with signs and symptoms of cardiac ischemia
  • Must input age and sex
12 lead ecg acquisition1
12 Lead ECG acquisition
  • 3 ECGs will be done on these patients:
    • First on scene as early as possible
    • Second prior to departure
    • Third upon arrival at medical facility
stemi bypass page 48
STEMI bypass (page 48)
  • If a STEMI positive ECG is identified and the patient meets all the criteria, and you can transport the patient within 60 minutes from STEMI identification contact SRHC
grab a pen page 48
GRAB A PEN!!!(page 48)
  • STEMI Bypass inclusion criteria: Maximum time from onset of symptoms is 12 hours.
  • If you have a patient who has symptoms for >12 hours and has a ******Meets ST Elevation MI criteria****** you may patch to the BHP for further direction.
procedure at southlake pci lab
Procedure at Southlake PCI lab
  • How do I communicate with SRHC that I have a STEMI patient when leaving the scene?
    • 1-905-895-4521 ext 7777
    • “This is a Simcoe County Paramedic, Unit 3---, we are transporting a Code STEMI patient, our ETA is ---, patient’s name, age, gender.”


When to call the BHP for termination of resuscitation?

medical tor page 42
Age > 18 years old

No ALS procedures

Cardiac in nature

3 No shocks on scene

Witnessed by EMS or Fire?

Any shocks delivered?

Was there a ROSC?

YES or uncertain = continue resuscitation & transport

NO = continue resuscitation and PATCH to BHP for medical TOR & continue transport.

Medical TOR (page 42)
trauma tor page 23 24
Trauma TOR (page 23 & 24)

Trauma TOR

  • Age > 16 years old
  • Blunt trauma = Big pads
    • Shock delivered, transport
    • No shock, No pulse, HR>0, transport
    • No shock, No pulse, No HR, patch for trauma TOR
  • Penetrating trauma = Petite pads (Electrodes)
    • HR >0, ED <20 minutes, transport
    • HR >0, ED >20 minutes, patch for trauma TOR
    • HR 0, patch for trauma TOR
  • Trauma patients that have received a TOR after a patch are to be left on the scene.
king lt

King LT

Click on video to start

king lt versus lma

Size 3,4,5

Inflation volume


Blind insertion

2 cuffs

Distal cuff inflates in the esophagus

Proximal cuff inflates at the base of the tongue



Inflation volume


Visualized insertion

Single cuff

King LT versus LMA
nrp page 32
NRP(page 32)
  • Prepare equipment
  • Team approach
  • 30 second blocks
anaphylaxis review


Continuing Education

  • Definition
  • Incidence
  • Pathophysiology
  • Signs and Symptoms
  • Diagnosis
  • Indication for Epinephrine SQ/IM
  • Case Presentation
definition of anaphylaxis
Definition of Anaphylaxis
  • A systemic reaction to a protein (antigen)
  • Caused by the release of immunoglobulin E (IgE)
  • IgE acts on mast cells and basophils
  • Mast cells and basophils release chemical mediators; including histamine
  • Histamine and other inflammatory agents act on smooth muscle, connective tissue and mucous glands


  • Difficult to get true numbers
  • Many reactions are mild and not reported or misdiagnosed
  • Up to 15% of population may be at risk
  • Anaphylactic and Anaphylactoid reactions occur due to the systemic release of chemical mediators from mast cells and basophils
  • Histamine is the primary mediator involved in urticaria, bronchospasm and anaphylactic shock
  • Histamine binds to H1 and H2 receptors
  • Binding of histamine to H1 and H2 receptors mediates pruritis, rhinorrhea, tachycardia, bronchospasm, hypotension, flushing and headache
signs and symptoms
Signs and Symptoms


  • Itching, Urticaria
  • Angioedema, flushing


  • Hoarseness, stridor
  • Dyspnea, wheezing, rhinitis


  • Nausea, vomiting
  • Cramping, diarrhea


signs and symptoms1
Signs and Symptoms


  • Dizziness,Chest Pain (uncommon)
  • Tachycardia, hypotension


  • Headache,
  • decreased LOA (due to hypotension +/-hypoxia),
  • seizures-uncommon
signs and symptoms2
Signs and Symptoms
  • Skin findings are the most common BUT up to 20% of patients do not have hives or other skin symptoms
  • Respiratory symptoms are the second most common
  • deaths result from severe bronchospasm and airway and laryngeal edema

Diagnosis is made clinically:

  • History of exposure to possible allergen followed by development of symptoms consistent with anaphylaxis
  • Development of urticaria, laryngeal edema, bronchospasm and/or hypotension with other signs associated with anaphylaxis
  • Rebound reactions can occur up to 24 hours later
Treatment ?
  • First line is Epinephrine SQ/IM
  • Other treatments: antihistamines, corticosteroids, bronchodilators, IV fluids without administration of epinephrine fail to prevent or relieve severe anaphylaxis
  • Epinephrine in the setting of anaphylaxis has greater benefit than risk
what are the indications for epi sq im
What are the Indications for Epi SQ/IM
  • Confirmed or suspected exposure to a probable allergen
  • Signs and symptoms of a severe anaphylactic reaction
    • Involvement of more than one body system
    • E.g.: Urticaria and nausea
    • E.g.: shortness of breath with wheezing and facial edema
    • OR any airway symptoms
case presentation
Case Presentation
  • 8 year old female began to have shortness of breath with wheezing and tightness in her throat while running a race at school
  • EMS is called 20 minutes later because the patient’s symptoms have not subsided and the patient now has a hoarse voice
  • Has had a similar reaction in the past but there was no specific allergen found
  • Pulse: 132, Resp: 24, BP: 80/62