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Region X SOP Review
December 2009 CE
Advocate Condell Medical Center
EMS System
Site Code #107200E-1209
Prepared by Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this module,
the EMS provider will be able to:
1. identify the signs and symptoms of an
acute asthma attack
2. identify the Region X SOP treatment for
acute asthma.
3. identify signs and symptoms of COPD.
4. identify the Region X SOP treatment for
COPD.
5. identify signs and symptoms of acute
pulmonary edema.
Objectives cont’d
6. identify the Region X SOP treatment for
acute pulmonary edema.
7. identify signs and symptoms of a
diabetic reaction.
8. identify the Region X SOP treatment for
a diabetic reaction.
9. identify signs and symptoms of
hypertensive crisis.
10.identify the Region X SOP treatment for
hypertensive crisis.
11.identify assessment of acute abdominal
pain.
Objectives cont’d
12. identify the Region X SOP treatment for
acute abdominal pain.
13. identify assessment of acute flank pain.
14.identify the Region X SOP treatment for
acute flank pain.
15.identify indications, contraindications,
dosing, side effects, and documentation for
Albuterol.
16. identify indications, contraindications,
dosing, side effects, and documentation for
Lasix.
Objectives cont’d
17. identify indications, contraindications,
dosing, side effects, and documentation for
Nitroglycerin.
18. identify indications, contraindications,
dosing, side effects, and documentation for
Morphine.
19. identify indications, contraindications,
dosing, side effects, and documentation for
Dextrose.
20. identify indications, contraindications,
dosing, side effects, and documentation for
Glucagon.
Respiratory System
Functional unit – the alveoli
Tiny air sacs at the distal end of the
respiratory system
Oxygen is removed from the air and
bound with hemoglobin in the blood
Carbon dioxide is displaced from
blood into the alveoli and blown out
as expired air
Measureable with ETCO2 detectors
Acute Asthma
Chronic inflammatory condition
Reversible widespread narrowing of
the airways (bronchospasm)
Symptoms usually develop in
response to a trigger
Viral infection, dust, cold, smoke
Produces:
 intermittent
wheezing
 excess mucous production
 edema of the airways
Acute Asthma
YOU CAN DIE FROM ASTHMA
Overall mortality rate 5%
1 in 100 hospitalized patients die per
year
Death rates are higher in persons less
than 35 years of age
Fastest growing asthma rates are in
children under 5
Triad of Asthma
Airway edema
Increased
mucous
production
Bronchospasm
Signs and Symptoms of Asthma
Bronchospasm
Constriction of smooth muscle that
surrounds the larger bronchi in the lungs
Air moving thru constricted tubes
vibrates the passageway creating
wheezing
Wheezing is widespread
Bronchoconstriction may be so severe
that no breath sounds are heard
Ominous sign
Signs and Symptoms of Asthma
Increased mucous production
Thick secretions plug the distal airways
More air trapping occurs
Dehydration makes secretions even
thicker which worsens air trapping
Taking antihistamines contributes to
increased dryness
Secretions thicken
Signs and Symptoms of Asthma
Bronchial edema
Wall of the bronchial tubes swell which
narrows the lumen (opening of the tube)
Swelling of bronchioles creates turbulent
airflow, wheezing, and air trapping
Treatment Goals for Asthma
Reverse bronchospasms with a
bronchodilator medication
Thin mucous secretions with
improving hydration (ie: IV fluids) and
expectorants
Reduce airway edema with
corticosteroid medications
Administered/prescribed in the hospital
COPD
Chronic obstructive pulmonary
disease
2 distinct entities
Emphysema
Chronic bronchitis
These populations have little to no
respiratory reserve
Hypoxic Drive
A rare occurrence in a small population of
the most chronic form of pulmonary
disease and in the end stages
Brain switches to a hypoxic drive to
breathe
Decreased levels of O2 stimulate breathing
Increased levels of CO2 no longer a stimulus
For the patient that becomes apneic, bag
them
Adult rate 10 - 12 breaths per minute
Allow for adequate exhalation time
Signs and Symptoms Emphysema
Barrel chest – chronic over inflation of
chest
Tachypnea – attempt to maintain
normal CO2 levels
Wasting muscle mass - use extreme
amounts of energy to breathe
Pursed lip breathing – attempt to
exhale as much CO2 as possible
“Pink puffer” – usually always good
color
Signs and Symptoms Chronic
Bronchitis
Excessive mucous production in
bronchial tree
Chronic or recurrent productive cough
Usually somewhat obese
Congested
Bluish complexion
Chronically elevated levels of CO2
Chronically lower levels of O2
Region X SOP
Asthma/COPD with Wheezing
Routine Medical Care
Obtain pulse oximetry before O2
application, if possible, as a baseline
Obtain VS, breath sounds, pulse oximetry
Albuterol 2.5 mg/3ml
O2 flow at 6L/minute
Transport
Contact Medical Control to consider CPAP
with COPD
Albuterol
Sympathomimetic, bronchodilator
Relaxes smooth muscles in bronchial
tree to relieve constriction
The drug has more selectivity in the
lungs than influence in the heart
Use to treat patient presenting with
wheezing
Could produce tachycardia
Administer 2.5 mg in 3 ml of solution for all
ages
Albuterol cont’d
Watch for tachycardia, tremors,
restlessness, dysrhythmias
For best results, patient needs to be
coached while inhaling
Encourage slower breaths
Encourage deeper breaths
Encourage inhaled breaths to be held
longer
Medication needs to get to the lungs
to be effective
Acute Pulmonary Edema
Lungs swell up with fluid that migrated
from the blood plasma into the walls
of the capillaries and alveoli of the
lungs
Gas exchange is compromised before
signs and symptoms are evident
One of the most common causes of
pulmonary edema is acute MI
Signs and Symptoms Acute
Pulmonary Edema
Crackles in lung bases at end of
inspiration – early sign
Alveoli popping open as lungs reach
maximum inflation
As condition worsens, crackles heard
higher up in the lung fields
Productive cough of watery sputum often
pink tinged (red blood cells)
Bubbling and foaming froth
From air forced out of fluid filled lungs
Signs and Symptoms cont’d
Dyspnea at rest
Extreme restlessness
Tachypnea
Tachycardia
Diaphoresis
Cyanosis
Decreased SpO2
Stable if B/P >100; unstable if B/P <100
Region X SOP – Stable Acute
Pulmonary Edema
Patient alert; skin warm & dry; B/P >100
Nitroglycerin 0.4 mg sl
Repeated every 3-5 minutes
Maximum 3 doses
Consider CPAP
Lasix 40 mg IVP
80 mg if patient takes oral Lasix at home
Morphine 2 mg slow IVP (over 2 min)
May repeat every 2 min as needed to a maximum
of 10 mg total
If wheezing, contact Medical Control to
consider Albuterol nebulizer
Transport
Lasix
Loop diuretic that inhibits reabsorption
of sodium and chloride and acts as a
diuretic
Diuretic effect takes about 20 minutes
Produces venodilation and pools
blood away from the heart to
decrease preload
Venodilation effect almost immediate
Lasix cont’d
Used in CHF and pulmonary edema
First as venodilator
Second as diuretic
Small potential of allergic reaction in
patients with allergy to antibiotic sulfa
drugs
Cautious use in hypotensive conditions
Administer 40 mg slow IVP
Give 80 mg if patient takes at home
May cause hearing loss or ringing in ears if
given rapidly over repeated doses
Nitroglycerin
Strong venodilator
Relaxes smooth muscles causing
dilation of venous and arterial blood
vessels
Reduces blood volume return to the
heart (preload) reducing the work-load of
the heart
Onset within minutes
Useful in pulmonary edema due to
vasodilation effect
Nitroglycerin cont’d
Avoid using if patient has taken a
viagra type drug within past 24-36
hours
Combination may produce irreversible
hypotension leading to shock or death
Administer 0.4 mg sl
May repeat up to 3 doses total
Carefully monitor B/P response before
and after each dose
Nitroglycerin cont’d
Side effects
Headache – venodilation
Hypotension – venodilation
Dizziness – venodilation
Postural syncope – venodilation
Nausea and vomiting – catecholamine
effect
Metallic taste – effect of medication
Morphine Sulfate
Narcotic analgesic, opioid
Depresses CNS activity
Creates sense of euphoria
Venodilator
Increases venous capacity pooling blood
away from returning to the heart
(decreased preload)
Used in pulmonary edema to reduce
preload
Morphine cont’d
If systolic B/P >100 can give
Morphine 2 mg IVP slowly over 2
minutes
May repeat every 2 minutes as needed
Maximum dose 10 mg
Evaluate blood pressure and
respiratory status prior to each dose
Region X SOP – Unstable Acute
Pulmonary Edema
Altered mental status; B/P < 100
Contact Medical Control
CPAP on orders of Medical Control
Consider Cardiogenic Shock Protocol
Dopamine drip to improve blood pressure
Treat dysrhythmias per protocol
If wheezing, contact Medical Control to
consider Albuterol nebulizer
Diabetes Mellitus
Impairment of the body’s ability to
metabolize simple carbohydrates (glucose)
Pancreas does not produce enough insulin
or cells do not respond to insulin produced
Develop elevated levels of glucose in the
blood and urine
Typical presentation
Urinating large quantities of urine
containing large amounts of glucose
Extreme thirst
Deterioration of body functions
Diabetes Mellitus
There is no cure
Treatment focuses on maintaining
glucose levels in the normal range
Dietary habits and activity must be
monitored
Will have the biggest impact on
improving quality of life and
avoiding complications
Type I Diabetes Mellitus
Most patients do not produce any
insulin
Generally strikes children more than
adults
Requires daily injections through out
their lives
Requires strict diet control
Requires a balance of activity
Type 2 Diabetes Mellitus
Most common form of diabetes
Glucose levels are elevated
Typically develops later in life
Becoming more common in younger
people
Body cannot effectively use the
insulin produced
Onset of signs and symptoms is
usually slow/gradual and often go
unrecognized by the patient
Type 2 Diabetes Mellitus
Signs and symptoms
Fatigue
Nausea
Frequent urination
Thirst
Unexplained weight loss
Blurred vision
Frequent infections that heal slowly
Being cranky, confused, or shaky
Unresponsiveness
Seizures
Hyperglycemia
Elevated levels of sugar
Excessive food intake
Insufficient insulin dosage
Infection or illness present
Stresses (ie: surgery, stress events)
Gradual onset (hours to days)
If untreated, will lead to diabetic
ketoacidosis
Life threatening condition of high levels
of certain acids in the body
Hypoglycemia
Too much insulin taken
Not enough food eaten
Brain is starved when it’s energy
source (glucose) is lacking
Cerebral dysfunction becomes
evident
Headache, confusion, slurred
speech, irritability, seizures, coma
Field Treatment Goals
Hyperglycemia
Patient is dehydrated and needs fluid
resuscitation
Hypoglycemia
The brain is starving for glucose and the
patient needs sugar as quickly as
possible
Signs and Symptoms
Hyperglycemia
Hours to days to develop
Warm and dry skin (dehydrated)
Normal to low B/P (dehydrated)
Normal to rapid pulse (dehydrated)
Very thirsty (dehydrated)
Deep, rapid breathing (Kussmauls)
(attempting to blow off excess acid CO2)
Sweet, fruity smell to breath (acetone)
Restless, just doesn’t feel well
Signs and Symptoms
Hypoglycemia – Insulin Shock
Quick onset within minutes
Pale and moist skin
Low B/P
Rapid, weak pulse
Normal or rapid breathing
Irritable, confused, seizures, or coma
Rapid response to treatment
Region x SOP - Hyperglycemia
Routine Medical Care
History of last med dose and if patient has
eaten and when
Obtain capillary blood glucose level
Use lancet and fingertip or forearm site
IV fluid challenge 200 ml
Reevaluate condition
May repeat fluid challenge 200 ml 2 more
times
Transport
Region X SOP - Hypoglycemia
Routine Medical Care
History of last med dose and if patient
has eaten and when
Obtain capillary blood glucose level
Use lancet and fingertip or forearm site
If blood sugar <60, administer Dextrose
Adult 16 and over – 50 ml 50% IVP/IO
1 – 15 years – D25% IVP/IO 2ml/kg
<1 year old – D12.5% IVP/IO 4ml/kg
Dextrose
A carbohydrate used to supply
glucose (sugar)
Rapid onset
Useful in known hypoglycemic case
and unresponsiveness for unknown
cause
Better to over treat the hyperglycemic
patient than to under treat the
hypoglycemic patient
Dextrose cont’d
Dose related to age
Adult 16 and over – 50 ml 50%
1 – 15 years old – D 25% 2 ml/kg
Under 1 – D 12.5% 4 ml/kg
Dilute D 25% 1:1 to make D 12.5%
Administer Dextrose slowly
Drug is hypertonic and acidic and can be
irritating to veins
Can be damaging to tissue if IV/med
infiltrates
Glucagon
A hormone to stimulate breakdown of
glycogen (stored form of glucose) in
the liver
Helpful when an IV cannot be
established and Dextrose is desired
Administer 1 mg / 1 unit
May take up to 20 minutes to work IF
there are glucose stores available
IV Established After Glucagon
IV established after Glucagon given
Recheck glucose level
If glucose level remains < 60, administer
Dextrose
Drug must be reconstituted prior to
administration
Roll reconstituted drug in hands
Check that all flecks have dissolved
Hypoglycemia Treatment
If no response to Dextrose in the adult
patient, repeat 50 ml D50% IVP
If unable to establish an IV, administer
Glucagon 1 unit (1 ml) IM
Glucagon may take up to 20 minutes to
work if glucose stores are available in
the liver
Hypertension
A major cardiovascular disease
Major contributing cause in many cases of
MI, CHF, and stroke
Results most often from advanced
atherosclerosis or arteriosclerosis
Present when B/P at rest is consistently
>140/90
Pre-hypertensive B/P >135/80
Majority of cases, patient asymptomatic
Hypertensive Emergencies
Acute, sudden elevation of B/P to levels
greater than 230/120
Some sources list B/P > 200/130
Due to high pressures, fluid is leaking into
the intracranial space increasing ICP
First symptoms:
Severe headache
Nausea/vomiting
Chronic hypertension is not the same as a
hypertensive emergency
Signs and Symptoms Hypertensive
Emergency
Severe headache (usually first
symptom)
Nausea and vomiting
Altered mental status
Agitated
Seizures
Coma
Visual changes
Epistaxis - nosebleed
Hypertensive Emergencies
Goal of treatment – slowly lower
blood pressure
Need to restore cerebral blood flow to
normal
If blood pressure is lowered too quickly,
cerebral blood flow would drop and
create greater complications
B/P best lowered in a controlled
environment
Best treatment in the field is supportive
care when transport time is minimal
Region X SOP Hypertensive
Emergency
Routine Medical Care
If you can, take B/P in both arms and
record comparison
Monitor VS and neuro status every 5
minutes
Lasix 40 mg IVP
80 mg if patient takes Lasix at home
Contact Medical control for possible
Nitroglycerin order
Transport
Hypertensive Emergencies
Lasix
Diuretic
Would take approximately 20 minutes
to be effective to pull some fluid out of
the cardiovascular system
Vasodilator
Vasodilation effects immediate
Blood pressure would drop in
relationship to the vasodilation of
blood vessels
Abdominal Organs
RUQ organs
Liver
Gallbladder
Parts of the large & small intestine
RLQ organs
Appendix
Parts of the large & small intestine
Right ovary, right fallopian tube
Abdominal Organs
LUQ organs
Spleen
Stomach
Parts of the large & small intestine
LLQ organs
Left ovary, left fallopian tube
Parts of the large & small intestine
Retroperitoneal Space Organs
Kidneys
Pancreas
Aorta
Categories of Abdominal Pain
Visceral pain
Originates from the organs
Dull, achy, intermittent, diffuse
Solid organs usually dull & persistent
Hollow organs usually crampy, colicky,
intermittent
Parietal pain
Arises from peritoneum – lining of
abdominal cavity
Sharp, constant especially with movement,
localized
Categories of Abdominal Pain
Tearing pain
A tearing sensation when blood tears
through a vessel lining
Indicates an abdominal aortic aneurysm
Part of aorta is in retroperitoneal space
so pain is felt in the back
Referred pain
Pain felt in a place distant from origin of
the pain (ie: gallbladder attack pain felt
in right shoulder)
Assessment Acute Abdominal Pain
O – onset – what was patient doing at
time of onset
Provocation/palliation – what
provokes/helps the pain
Quality – description in patient’s own
words
Region/radiation – have patient point
Severity – on scale of 0 to 10
Time – how long has the pain been
present
Assessment of Abdominal Pain
General appearance & posture
Lying quiet? Cannot lay still? Guarding?
Visually inspect abdomen first
Marks? Bruises?
Distention?
Auscultating
Not that helpful in the field
Percussion
Not that helpful in the field
Assessment cont’d
Palpation
Extremely important and helpful
Can define area affected
Can identify the organ involved
Palpate the most painful area last
Use gentle pressure with finger pads
Check for:
Muscle tenseness or absence
Masses or pulsations
– Stop palpation if found
Tenderness
Abdominal Palpation
Need to check all 4 quadrants
Upper quadrants often only areas
palpated when stopping at the
waistband of pants
Anatomy Flank Area
Area outside the peritoneum
Between the abdomen and the back
Organs included
Kidneys
Pancreas
Aorta
Assessment of Flank Pain
Assess the patient following the
OPQRST mnemonic
Urological organs
Most common pain is visceral and
referred
Achiness, cramping
Referred pain to the neck or shoulder
Common urological problem
Kidney stone (renal calculi)
Pyelonephritis – kidney infection
Medical problem - pancreatitis
Abdominal Complaints To Evaluate
Pain
Nausea and/or vomiting
Distention
Alteration in menstrual cycle in females
Bloody discharge
Vomitus
Stools
Urine
Region X SOP – Stable Acute
Abdominal / Flank Pain
Alert, skin warm & dry, B/P >100
Routine Medical Care
Watch for aspiration from vomiting
Menstrual history in female
Contact Medical Control for pain
management
Be the advocate for the patient
After assessment, if the patient needs pain
control, request an order for Morphine
Transport
Region X SOP Unstable Acute
Abdominal / Flank Pain
Altered level of consciousness, B/P <100
Routine Medical Care
Watch for aspiration from vomiting
Menstrual history in female
Establish IV (2 sites if possible)
Contact Medical Control for pain
management
IV fluid challenge in 200 ml increments
Peds fluid challenge 20 ml/kg
Case Studies
Use the following case studies as
discussion points
Determine a general impression
Discuss the protocol to follow for
treatment you feel is indicated
Additional information is in the notes
section of the slide
Case Study #1
You are responding to a local church for
an elderly woman who fainted
Upon arrival:
Conscious but confused
Complains of shortness of breath and a
feeling of lightheadedness
Pale, diaphoretic
Increased respiratory rate; adequate depth
Weak radial pulse
General impression? Plan of action?
Case Study #1
General impression (not all inclusive):
Cardiac
Dysrhythmia?
Acute MI?
Respiratory
CHF?
Hypoglycemic
What’s blood sugar?
History of diabetes?
Environmental
Heat – too hot in the room
Stress – personal, of the situation
Case Study #1 - Treatment
Minimally Routine Medical Care
IV – O2-monitor
Obtain vital signs
Any clue obtained by the results?
Blood glucose level
Level <60 or high (ie: >200)?
Obtain breath sounds
Any abnormalities to treat?
What kind of supplemental oxygen does the
patient need?
Any other care you can think of?
Case Study #2
You are called to the scene for a 16
year-old female with abdominal pain
The father greets you at the door
The patient is alert, lying in bed in the
fetal position, pale, writhing in pain,
and complaining of nausea
P – 118; RR 24
What’s your impression?
How do you progress with
assessment?
Case Study #2
Impression (not all inclusive):







Appendicitis
Ruptured ovarian cyst
Ectopic pregnancy
Menstrual cramps
Gastroenteritis
Kidney problem
Psychological emergency
At 16, she is to be treated with respect and
dignity. She is still a minor but capable of
supplying a good portion of her medical
history. You will need privacy for part of the
exam.
Case Study #2
Further assessment:
B/P - 130/88; P - 118; RR – 24
Skin pale, warm, moist
Pain in the RLQ; ranked 9/10
Pain radiates to the groin and back
LMP – less than 2 months ago; a period
is due in 11/2 months
Taking an extended release birth control pill
to regulate menstrual cycle
Patient denies possibility of pregnancy
Father is insulted you asked the question!
Case Study #2
Patient is 16
Do you treat her as a pediatric patient or
follow the adult SOP’s?
16 and over – follow adult SOP’s
What is included in obtaining a history
of the present illness?
OPQRST
Also helpful approach to remember what
to document
Case Study #2
The father requests to ride with the
patient to the hospital
What is your department policy for
transporting family members with the
patient?
Do you allow this?
Where does the family member sit for
transport?
Does it make a difference if it is a
pediatric patient versus adult patient?
Case Study #2
In ambulance, patient states she has
forgotten some of her birth control
pills
Patient admits to being sexually
active
Patient “freaking out” fearing she may be
pregnant, worried father will “kill her”
General impression still includes
many possibilities
Ectopic pregnancy probably at top of list
What care is rendered?
Case Study #2
Continue to monitor vital signs
Why are pulse & respiration rates up?
Pain
Anxiety
Establish IV
KVO / TKO for now
Transport in position of comfort
Watch for vomiting and aspiration
Case Study #2
What do you do for pain control?
Act as an advocate for the patient
Contact Medical Control
Give report
Request an order for Morphine if pain
levels remain elevated
Morphine 2 mg slow IVP
May repeat 2 mg every 2 minutes
Maximum total dose is 10 mg
Case Study #3
You respond to the scene for a 65 year-old
male with complaints of difficulty breathing
Appears anxious, tired, tells you he can’t
catch his breath
Using accessory muscles; leaning forward in
the tripod position
Pale, diaphoretic
B/P 108/54; P – 110; RR – 32; Temp 1020F
SpO2 75%
Monitor – sinus tach, occ PVC’s
Case Study #3
Your patient is no longer interacting
with you due to worsening respiratory
effort
B/P 106 by palpation; P – 102; RR – 30
SpO2 72% on 100% non-rebreather
How do you obtain a history?
What is your general impression?
What interventions are required?
Case Study #3
Poor respiratory effort
Patient extremely hypoxic
With ineffective respirations may be retaining
CO2
Depressed O2 levels and elevated CO2 levels
negatively affect level of consciousness and
respiratory effort
Body becoming hypoxic and acidotic
Prone to dysrhythmias
Medications less effective in this environment of
hypoxia and acidosis
Case Study #3
History gathering
From patient if possible
From family and bystanders
From environment
Medical alert tags
Medication bottles
Any other clues from scene
General impression
Respiratory distress
More respiratory assessment may narrow the
impression
Case Study #3
Patient with bilateral rales
Wife states he has slept in the recliner
for the past 3 nights
Pedal edema present up to his mid
calf area
Patient has run out of medications
over 3 weeks ago
History of CHF, MI, diabetes, and gout
Case Study #3
Impression – Acute pulmonary edema
Treatment (B/P 106 systolic)
Begin O2 via non-rebreather
May need to switch to bagging
Nitroglycerin 0.4 mg sl
Evaluate the patient’s level of
consciousness
Consider CPAP
CPAP buys time for meds to take
effect
Lasix 40 mg IVP (80 mg if takes Lasix)
Case Study #3
Use of respiratory adjuncts
Suction to remove secretions
Limit time to 15 seconds for adult
Oral airway if no gag response
Nasopharyngeal – with or without gag
response
BVM – to support the patient’s
respiratory effort
Difficult at best to maintain an
adequate seal and ventilate with
enough volume especially for one
person
BVM Support to Patients with
Obstructive Disease (ie: COPD)
These patients have difficulty exhaling
Over bagging
Increased thoracic pressures -pneumothorax
Limiting venous return to the heart – cardiac
arrest
Do not bag a patient based on your level of
adrenaline!!!
Standard bagging rate 10 - 12 breaths per
minute (once every 5 - 6 seconds)
May need to slow down if exhalation needs
more time especially in patients with COPD
Case Study #4
You have a 35 year-old female who
“passed out”
Upon arrival:
Patient responsive to verbal stimuli,
confused
Pale, cool, diaphoretic
B/P 122/68; P – 130; R – 22; SpO2 97%
Impressions?
Treatment?
Case Study #4
Impressions
Hypoglycemia – check blood sugar level
Consider dysrhythmias – place on
cardiac monitor
Hypotension – check for evidence of low
blood volume/flow even transient
Overdose – check for evidence of
improper intake
Blood glucose level - 27
Case Study #4
Treatment of hypoglycemia
Begin IV
Administer 50 ml of D50
Watch for infiltration
Dextrose is irritating to veins
Obtaining a release
Document a blood sugar >60 prior to
leaving the scene
Document advice to contact personal
physician
Document if anyone is staying with
patient
Case Study #5
You respond to a 57 year-old male patient
with sudden onset of right flank pain
radiating down towards his groin.
Patient is writhing in pain, anxious, pale,
diaphoretic
B/P 150/88; P – 110; R – 22
History diabetes, MI, hypertension, kidney
stones
Impression?
Treatment?
Case Study #5
Sounds like a kidney stone
Could be AAA
No pulsatile mass found
Blood pressures equal in right and left
arms
Equal strength felt in pedal pulses
You decide it’s a kidney stone
What can make the patient feel more
comfortable?
Case Study #5
Be an advocate for the patient
Contact Medical Control for pain control
Request Morphine 2 mg slow IVP
Recognize that these patients are
experiencing one of the most painful
diseases and will need large amounts
of pain medications
Pain does not abate until the stone
moves
Review
What do crackles sound like?
Like rubbing pieces of your hair together
next to your ear
Like crinkling a bag of potato chips
Why is nitroglycerin given in
pulmonary edema?
Acts as a venodilator to pull blood away
from the heart
Review
What’s the dose of Lasix for a patient
taking it at home?
Dose increased to 80 mg
What intervention can be done for
pain control for the patient with
abdominal pain?
No standing order; you must call Medical
control for orders
Review
What information should be obtained
during assessment, history gathering
and included in documentation?
Onset
Provocation/palliation
Quality of pain
Radiation
Severity on 0 to 10 scale
Time of onset of symptoms
Bibliography
Bledsoe, B. Porter, R., Cherry, R. Paramedic
Principles & Practices. Brady. 2009.
Caroline, N. Emergency Care in the Streets. 6th
Edition. Jones & Bartlett. 2008.
Edmunds, M. Introduction to Clinical
Pharmacology. Mosby. 2006.
Limmer, D., O’Keefe, M. Emergency Care, 10th
Edition. Prentice Hall. 2005.
Region X SOP March 2007; Amended January,
2008.
www.americanheart.org