Download Module II - Advocate Health Care

Endocrinology,
Gastrointestinal Disorders,
Renal/Urology Disorders,
Rhythm Review
Condell Medical Center
EMS System
ECRN CE
Prepared by: S. Hopkins, RN, BSN, EMT-P
Objectives
• Upon successful completion of this module, the
ECRN should be able to:
– identify the function of the endocrine system
– distinguish a variety of medical disorders of the
endocrine system
– describe the type of pain experienced for
gastrointestinal and genitourinary disorders
– identify and appropriately state interventions for a
variety of EKG rhythms
– understand a variety of Region X SOP’s and the ECRN
impact
– successfully complete the quiz with a score of > 80%
Endocrine System
• Composed of glands that secrete hormones
into the circulatory system
• Helps regulate various metabolic functions
• Hormones function in a lock and key
fashion
• All hormones operate
within a feedback system
Hormones
• Act on target organs elsewhere in the body
• Control and coordinate wide spread
processes on organs, tissues, or general
effects on the entire body
– homeostasis
– reproduction
– growth & development
– metabolism
– response to stress
Endocrine Glands
Hypothalamus
– located deep within the cerebrum of the
brain; serves as a connection between the
central nervous system (CNS) and the
endocrine system
– secretes hormones that make other endocrine
glands secrete hormones
Pituitary - anterior & posterior
– located in the brain; size of a pea
– secretes hormones essential to growth,
reproduction, and water balance in the body
Endocrine Glands cont’d
Thyroid
– 2 lobes located in anterior neck
– plays important role in controlling
metabolism
Parathyroid
– normally 4 glands found next to thyroid
gland
– secretes hormone to increase blood calcium
levels
Endocrine Glands cont’d
Thymus gland
– located in mediastinum behind sternum
– during childhood secretes a hormone critical in
maturing T lymphocytes (cells responsible for cellmediated immunity)
Pancreas
– located in upper retroperitoneum behind stomach
– secretes digestive enzymes for digestion of fats &
proteins
– controls production or inhibition of the hormones
glucagon & insulin
Endocrine Glands cont’d
Adrenal gland
– located on superior surface of each kidney
– adrenal medulla - secretes the catecholamine
hormones epinephrine & norepinephrine
– adrenal cortex - secretes 3 steroidal hormones
Gonads
– chief responsibility for sexual maturation or
puberty and subsequent reproduction
– ovaries produce eggs
– testes produce sperm
Regulation of Hormone Secretion
• Hormones operate within a positive or negative
feedback system to maintain homeostasis
• Negative feedback
– Most common feedback mechanism
– Usually refers to an increase in the serum
level of hormone or hormone-related
substance that suppresses further hormone
output
– Hormone production is stimulated when the
serum levels fall
Negative Feedback Mechanism
Specific Disorders of the
Endocrine System
• Disorders of the endocrine system arise
from:
– the effects of an imbalance in the
production of one or more hormones
– the effects of an alteration in the body’s
ability to use the hormones produced
Specific Disorders of the
Endocrine System
• Clinical effects of endocrine gland
imbalance are determined by:
the degree of dysfunction
the age and gender of the affected person
Disorders of The Thyroid Gland
• Usually seen more as part of the medical
history than as a medical emergency
• Complications of thyroid disorders more
likely to be seen
– hyperthyroidism - too much thyroid hormone in
the blood (goiter)
– thyrotoxicosis - prolonged exposure to excess
thyroid hormones (Grave’s disease)
– hypothyroidism - inadequate thyroid hormone
– myxedema - long term exposure to inadequate
levels of thyroid hormones
Grave’s Disease
• A type of excessive thyroid activity
characterized by a generalized enlargement of
the gland (goiter), leading to a swollen neck and
often protruding eyes (exophthalmos)
– More common in women than men (6 times)
– Typical onset young adulthood (20’s & 30’s)
– May be due to an autoimmune process
in which an antibody stimulates the
thyroid cells
– Strong hereditary role in
predisposition of the disorder
Grave’s Disease
• Impact on EMS providers & ED staff
cardiac dysfunction is a common event
prompting an ED visit
• tachycardia or new-onset atrial fibrillation
in absence of cardiac history
• Other signs & symptoms
agitation, emotional changeability,
insomnia, poor heat tolerance, weight loss
with increased appetite, weakness, dyspnea
Thyrotoxicosis
• A term that refers to any toxic condition that
results from prolonged excess thyroid hormone
• Thyroid storm is a heightened and life-threatening
manifestation of thyroid hyperfunction
– A relatively rare condition; can be fatal
– Usually associated with exposure to physiological
stress (trauma, infection)
– signs & symptoms indicate extreme hypermetabolic
state (high fever (1060F), irritability, delirium or coma,
tachycardia, hypotension, vomiting, diarrhea)
• EMS field care - supportive, rapid transport
Myxedema
• Rare condition of long term
exposure to inadequate levels
thyroid hormones
• 4 times more common in women
• Low metabolic state with poor
organ function
• Lethargy, cold intolerance, 
mental function, puffy face, thin
hair, pale & cool skin
• Triggers for myxedema coma
– infection, trauma, cold temp
Myxedema Coma
• Myxedema coma difficult to identify
• Impact on EMS providers & ED staff
– Heart failure not uncommon
– Focus on maintenance of ABC’s
– Monitor pulmonary and cardiac systems closely
– Rapid transport from the field is important
– Active rewarming in field not indicated
• may cause cardiac dysrhythmias
• vasodilation may cause cardiovascular
collapse
Disorders of Adrenal Glands
Adrenal cortex - outer portion of adrenal gland
• Secretes steroidal hormones
– glucocorticoids - increase blood glucose levels
– mineralocorticoids - contributes to salt & fluid
balance
– androgenic hormones - influences similar to the
gonads (role in puberty and reproduction)
• Two medical emergencies of the adrenal cortex
Cushing’s syndrome
Addison’s disease
Cushing’s Syndrome
• Caused by an abnormally high circulating level
of corticosteroid hormones produced naturally
by the adrenal glands
• May be produced:
– Directly by an adrenal gland tumor
– By prolonged administration of corticosteroid
drugs (ie: Prednisone, hydrocortisone)
– By enlargement of both adrenal glands due to
a pituitary tumor
• Relatively common problem of adrenals
Adrenal glands
Adrenal glands
Kidneys
Cushing’s Syndrome
• Characteristic appearance
– Face appears round (“moon-faced”) and red
– Trunk tends to become obese from disturbances
in fat metabolism; “buffalo hump” on back
– Limbs become wasted from muscle atrophy
– Mood swings , impaired concentration
– Purple stretch marks may appear on the
abdomen, thighs, and breasts
– Skin often thins and bruises easily
– Weakened bones are at increased risk for
fracture
Moon Face
Cushing’s
Syndrome
Signs &
Symptoms
Management of Cushing’s
Syndrome
• FYI: higher incidence of cardiovascular
disease
stroke
hypertension
• Fragile skin
caution with IV starts
handle the patient carefully to avoid trauma
to their skin
• Treat symptoms as presented
Addison’s Disease
• Pathophysiology
– Reduction in Adrenal steroids
Glucocorticoids
Mineralocorticoids
Androgens
– Most common cause is idiopathic atrophy of
adrenal tissue (cause unknown)
– Less common causes include hemorrhage,
infarctions, fungal infections, auto immune
disease, therapy with steroids (ie: prednisone)
Addison’s Disease
• Signs and symptoms
– Progressive weakness, fatigue
– Decreased appetite & weight loss
– Hyperpigmentation of skin, especially over
sun-exposed skin areas
– Disturbances in water & electrolyte balance
– Low blood volume
– EKG changes
– Abrupt stoppage of steroids may trigger
Addisonian crisis with cardiovascular
collapse
Addison’s Disease
• Management
– Evaluate ABC’s & correct issues
– Cardiac status - watch for dysrhythmias
and circulatory collapse
• Fluid resuscitation
– Respiratory status - evaluate SaO2 levels
– Blood glucose levels
• Hypoglycemia very common
Diabetes Mellitus
• Disease marked by inadequate insulin activity in
the body
• Glucose is important to all body cells but critical
for the brain
– Glucose only substance used by the brain for
energy
• Insulin maintains normal blood glucose levels
– Enables body to store energy as glycogen,
protein & fats
– Action of insulin allows glucose to flow into
cells
Typical Blood Glucose Levels
• Healthy persons
–
–
–
–
Overnight fast - 80-90 mg/dL
1st hour after a meal - 120-140 mg/dL
<80mg/dL reflects hypoglycemia
>140 mg/dL reflects hyperglycemia
• Intervention necessary
– Hypoglycemia -blood glucose <60 mg/dL
• Hyperglycemia - blood glucose >300mg/dL
not uncommon
Type I Diabetes
• Low or absent production of insulin in the
pancreas
• Too much sugar, not enough insulin
• Patients require supplemental insulin
• If untreated, glucose levels rise
– excess glucose spills into urine; patient loses
large amounts of water (becomes
dehydrated); fatty acids used as energy source
resulting in ketosis from fat catabolism
Untreated Type I Diabetes
• Signs & symptoms due to elevated blood
glucose levels
Polydipsia (constant thirst)
Polyuria (excessive urination)
Polyphagia (ravenous appetite)
Weakness
Weight loss
• Above signs & symptoms are what usually
prompt people to seek a medical checkup
for “not feeling well”
Type II Diabetes
• More common than Type I diabetes (90% of
cases)
• Moderate decline in insulin production and
inefficient use of the insulin that is produced
• Risk factors: heredity, obesity
• Treatment: dietary changes, increased
exercise, oral hypoglycemics (to stimulate
insulin production), possible addition of
insulin if necessary
Diabetic Ketoacidosis(Diabetic Coma)
•
•
•
•
•
•
Too much sugar, not enough insulin
Onset slow (12 - 24 hours)
Increased urination; dehydration (warm, dry skin)
Excessive hunger and thirst
Tachycardia & weakness (volume depletion)
Ketoacidosis  Kussmaul’s respirations (deep and
rapid) to exhale & get rid of increased CO2 levels
(an acid)
• Decline in mental function
• Low potassium - cardiac dysrhythmias
Diabetic Coma - Hyperglycemia
• ABC’s addressed
• Search for medic alert bracelet (EMS should
check for insulin in refrigerator at home)
• Elevated blood glucose levels (not uncommon
to be >300)
• Fluid resuscitation to treat dehydration
• The higher the glucose level, the more critical
the situation and the sicker the patient
Insulin Shock - Hypoglycemia
•
•
•
•
•
Too much insulin, not enough sugar
Onset rapid
Bizarre, unusual, inappropriate behavior
Diaphoretic, tachycardic
Seizures at critically low glucose levels
– These seizures are most effectively treated by
administering Dextrose to restore the glucose
levels
• Rapid recovery with correct treatment
– supplemental glucose
Insulin Shock - Hypoglycemia
• ABC’s addressed
• Search for medical alert bracelet (EMS to check for
insulin in refrigerator at home)
• Treated when blood sugar drops below 60
• Obtain IV access to administer dextrose (EMS dosing)
– Adult - D50% (50 ml)
– Child (1to 15) - D25% (2 ml/kg)
– Child <1 - D12.5% (4 ml/kg)
• 1:1 dilution of D25% and normal saline
• Lack of IV access (EMS dosing protocol)
– Glucagon IM: adult 1 mg; peds 0.1 mg/kg (max 1mg)
Glucagon vs Dextrose
• Glucagon
– a hormone, not a sugar
– helps release stores of sugar if there are any in the
liver; does not supply sugar itself
– is not always effective; can take up to 20 minutes
• EMS calls and states they had no IV access,
Glucagon was given, patient remains with an altered
level of consciousness and now they have IV access.
Can they give Dextrose IVP?
• The ECRN should order EMS to recheck the glucose
level and, if indicated (<60), administer Dextrose
Gestational Diabetes
• Onset can occur during pregnancy
• While pregnant, most women require 2-3
times more insulin than would usually be
required when not pregnant
• During pregnancy, must be treated with
insulin vs oral medication
– insulin does not cross placental barrier;
oral diabetic medication does
• After delivery blood glucose levels usually
return to normal
Gastrointestinal System
Gastrointestinal Emergencies
• GI system includes from the mouth to anus and
all parts in between
• Risk factors for disease (usually self-induced)
– excessive alcohol consumption
– excessive smoking
– increased stress
– ingestion of caustic substances
– poor bowel habits
• Pain is the hallmark of acute abdominal problems
– visceral, somatic, or referred
Visceral Pain
• Caused by inflammation, distention (inflation of
the organ), or ischemia (inadequate blood flow)
– Pain vague, dull, or crampy
– Is generally diffuse and difficult to localize
• Examples (most often hollow organs)
– gallbladder (cholecystitis)
– appendix (appendicitis)
• Presentation (from sympathetic stimulation)
– nausea & vomiting
– diaphoresis
– tachycardia
Somatic Pain
• Produced by bacterial or chemical irritation of
nerve fibers in the peritoneum (peritonitis)
– Is usually constant and localized to a specific
area
– Often described as sharp or stabbing
• Examples
– ruptured appendix
– perforated ulcer
– inflamed pancreas
• Peritonitis can lead to sepsis & death
Somatic Pain
• Presentation
– Patient often hesitant to move
– Lies on their back or side with legs flexed to
prevent additional pain from stimulation of
the peritoneal area
– Often exhibits involuntary guarding of the
abdomen
– Rebound tenderness often noted during the
physical examination
Referred Pain
• Pain in a part of the body considerably removed
from the tissues that cause the pain
– Results from neural pathways from various
organs passing thru or over a region where the
organ was initially formed in the fetal stage
– Examples
• diaphragm injury refers pain to neck or shoulders
• dissecting abdominal aneurysm refers pain
between shoulder blades
• appendicitis refers pain to periumbilical area
• gallbladder refers pain to right shoulder
Referred
Pain:
Anterior
View
Referred
Pain:
Posterior
View
Disease Entities
Upper GI Disease:
• Gastroenteritis
• Gastritis
• Peptic ulcer disease
Lower GI Disease:
• Colitis
• Crohn’s disease
• Diverticulitis
• Bowel obstruction
Other Organ Disease:
• Appendicitis
• Cholecystitis
• Pancreatitis
• Acute hepatitis
Gastroenteritis
• Inflammation of the stomach and intestines that
accompanies numerous GI disorders
• Causes:
– bacteria or viral infections, chemical toxins,
and other conditions
• Signs and symptoms:
– anorexia (loss of appetite), nausea, vomiting,
abdominal pain
• EMS Field Management
– supportive
Gastritis
• An acute or chronic inflammation of the gastric
mucosa
• Causes
– hyperacidity
– alcohol or drug ingestion
– infection
• Signs and symptoms:
– epigastric pain
– nausea and vomiting
– bleeding
Peptic Ulcer Disease
• Erosions in the GI tract from gastric acid
• Duodenal ulcers - most frequently in proximal
duodenum
– most common 25-50 years old & in those
under stress
– pain at night when the stomach is empty
• Gastric ulcers - in the stomach
– more common over 50 years of age & in jobs
requiring physical activity
– usually no pain at night; pain on full stomach
Peptic Ulcer Disease
• Causes of peptic ulcer disease
H. pylori infection (treated with
antibiotics)
Nonsteroidal anti-inflammatory drug use
• aspirin, Motrin, Advil
Acid stimulating products
• alcohol, nicotine
Acid secreting tumor
• Zollinger-Ellison syndrome
Colitis
• An inflammatory condition of the large
intestine characterized by severe diarrhea and
ulceration of the mucosa of the intestine
(ulcerative colitis)
• Incidence - most often 20-40 year olds
• Cause is unknown
• Signs and symptoms
– Nausea, vomiting, weight loss
– Significant pain - cramping & colicky
– Grossly bloody stools or stool containing
mucus
Crohn’s Disease
• A chronic, inflammatory bowel disease thought
to be of autoimmune etiology, usually affecting
the ileum, the colon, or both structures
• Exact cause unknown
• Most prevalent in: white females, those under
stress, and in the Jewish population
• The diseased segments associated with Crohn’s
disease may be separated by normal bowel
segments or skip areas
– Formation of fistulas from the diseased
bowel to the anus, vagina, skin surface, or to
other loops of bowel are common
Crohn’s Disease
• Signs and symptoms:
– GI bleeding
– frequent diarrhea
– abdominal cramping
– diffuse abdominal pain
– nausea/vomiting/diarrhea
– fever and chills
– weakness, anorexia, weight loss
Diverticulitis
• A diverticulum is a sac or pouch that develops in
the wall of the colon
– Common development with advancing years
– Associated with diets low in fiber
• Diverticulitis is inflammation of diverticula
• Signs and symptoms:
– Fever, anorexia, nausea, lower left
sided pain, bright-red rectal bleeding
• Complications:
– Hypovolemic shock and sepsis
Bowel Obstruction
• A partial or complete blockage of the large or
small intestines
• Causes:
– adhesions, hernias, fecal impaction, polyps,
tumors
• Signs and symptoms:
– decreased appetite, nausea and vomiting,
diffuse abdominal pain, constipation, and
abdominal distention
• If untreated can lead to death
Appendicitis
• A common abdominal emergency that occurs
when the opening between the lumen of the
appendix and the cecum is obstructed by fecal
material or from inflammation from viral or
bacterial infection
• Signs and symptoms:
– early abdominal pain is diffuse, colicky, & in
periumbilical area (later RLQ), abdominal
tenderness & guarding, nausea,
vomiting, chills, low-grade fever, anorexia
• If ruptured, increased risk of peritonitis
Cholecystitis
• Inflammation of the gallbladder, most often
associated with the presence of gallstones
• Incidence
– more common in women 30-50
• Signs & symptoms
– pain, often colicky, in RUQ with referral to right
shoulder
– pain often after high fat content meal
– nausea, vomiting common
– pale, cool, clammy skin (sympathetic response)
• Giving Morphine may increase spasms
Pancreatitis
• Inflammation of the pancreas
• Alcoholism causes 80% of cases in the USA
• Signs and symptoms:
– severe abdominal pain
• localized to LUQ or referred to back or
epigastric area
– nausea and uncontrolled vomiting & retching
– abdominal tenderness and distention
– fever, tachycardia, diaphoresis
– sepsis & shock possible, 30-40% mortality
Acute Hepatitis
• Inflammation of the liver
• Signs & symptoms related to severity of disease
– Associated with the sudden onset of malaise,
weakness, anorexia, intermittent nausea and
vomiting, and dull right upper quadrant pain or
referral to right shoulder
– Usually followed within 1 week by the onset of
jaundice of skin & sclera, dark urine, clay
colored stool
Risk Factors for Hepatitis A
• Spread by fecal-oral route
Health care practice without BSI (body substance
isolation) or infection control precautions
Household or sexual contact with an infected
person
Living in an area with HAV outbreak
Traveling to developing countries
Poor handwashing hygiene practice especially
after toileting
• Disease often self-limiting, lasts 2-8 weeks, low
mortality rate
Risk Factors for Hepatitis B
• “Serum hepatitis” transmitted as bloodborne
pathogen - can stay active in body fluids outside
body for days
Health care practice without infection control
precautions
Infant born to HBV infected mother
Engaging in sex with infected partners and/or
multiple partners
Drug use by injection
Patients receiving hemodialysis
• Incidence  with vaccine use
Risk Factors for Hepatitis C
Health care practice without infection control
precautions
Blood transfusion recipients before July 1992
Engaging in sex with infected partners and/or
multiple partners
Drug use by injection
Patients receiving
hemodialysis
• #1 reason for liver transplant
need in USA
• Currently no vaccine
1991
Abdominal Pain What Could It Be?
• Naval area
– small intestine
– appendix
• Upper middle abdomen
(called “epigastric” area)
– stomach disorders
• Left upper quadrant
– uncommon area for pain
– colon, stomach, spleen,
pancreas
• Right upper quadrant
– gallbaldder, liver
• Lower middle abdomen
– colon disorder
– for women: UTI, PID
• Lower left abdomen
– lower colon
• Lower right abdomen
– colon, appendicitis
• Right shoulder
– gallbladder
• Between shoulder blades
– pancreas
Assessing Abdominal Pain
• Onset - when did it begin
• Provocation/palliation - what makes the pain
worse/better
• Quality - described in the patient’s own words
• Region/radiation - if the patient can use one
finger the pain is localized; if the patient rubs
their hands over the general entire abdomen it is
diffuse
• Severity - on a scale of 0-10 (0 being no pain
and 10 being the worse)
• Time - how long has the pain been present?
Management of GI Problems
• Majority of care is supportive and aimed at
treating signs and symptoms presented
• Position of comfort with ability to protect airway
in the case of vomiting
• Abdominal pain control - EMS needs to contact
medical control for medication orders (Morphine
2 mg IVP every 2 minutes, max 10 mg)
• IV to replace fluid loss (vomiting, diarrhea,
internal hemorrhage)
• Shock (hypovolemic, septic) possible and then
aggressive care required
Renal/ Urology System
• Functions of the urinary system
maintains blood volume
maintains proper balance of water, electrolytes
and pH
retains key compounds in the bloodstream
excretes waste
controls arterial blood pressure
• Leading causes of end-stage renal failure
poorly controlled diabetes
uncontrolled or inadequately controlled  B/P
Renal Calculus (Kidney Stones)
Renal Calculus
• Crystal aggregation in kidney’s collecting
system
• Severe pain due to movement of stone
through the urinary system
• Kidney stones recognized as one of the
most painful of human problems
• Pain starts subtle and quickly escalates
Kidney Stone
• Pain starts vague over 1 flank & quickly
becomes sharp in flank and radiating down
and around toward the groin
• Patient agitated, uncomfortable, restless
• Skin cool, pale, clammy
• B/P and heart rate elevated due to pain
• Nausea & vomiting due to pain
EMS Management-Kidney Stones
• Majority of care is supportive and aimed at
treating signs and symptoms presented
• Position of comfort with ability to protect
airway in the case of vomiting
• Flank pain - EMS needs to contact medical
control for medication orders (ie: morphine)
(Abdominal/Flank Pain SOP)
• If patient is unstable with B/P <100mmHg,
establish IV sites and give fluid challenge
(200 ml increments)
Prevention Strategies for Renal
Calculus
• Increase water consumption
• Take daily supplements of Vitamin B6 and
magnesium (to reduce formation of oxalates)
• Avoid foods that raise uric acid levels (ie: anchovies,
sardines)
• Reduce uric acid by eating a low-protein diet
• Limit salt intake to reduce the level of calcium oxalate
in the urine
• Avoid foods containing calcium oxalate (ie: chocolate,
celery, grapes, strawberries, beans, asparagus
Identifying a variety of EKG
rhythms and knowing the
Region X SOP for that
particular rhythm
Rhythm Identification
• What is this rhythm?
• What is your intervention?
Ventricular Tachycardia
• If stable with pulse:
– Amiodarone 150 mg diluted in 100 ml D5W IVPB
over 20 minutes
or (EMS choice)
– Lidocaine 0.75 mg/kg IVP bolus
– Contact Medical Control for further bolus/drip orders
• If no pulse - treat like ventricular fibrillation
– emphasis on good quality CPR
– switch CPR compressor every 2 minutes to keep CPR
effective
– all shocks given at max joules & singular
Rhythm Identification
• What is this rhythm?
• What intervention is necessary?
EMS Tx-Ventricular Fibrillation
•
•
•
•
•
If arrest <4-5 minutes, CPR until defibrillator ready
If arrest >4-5 minutes, CPR for 2 minutes
Single shocks at max output of unit
Epinephrine 1:10,000 1 mg every 3-5 minutes
EMS choice of one antidysrhythmic alternated with
Epinephrine:
– Amiodarone 300 mg rapid IVP 1st dose
• repeat 150 mg IVP in 5 minutes (2nd dose) OR
– Lidocaine 1.5 mg/kg IVP 1st dose
• repeat 0.75 mg/kg in 5 minutes (2nd dose)
Rhythm Identification
• What is this rhythm?
• What intervention is necessary?
EMS Tx-Third Degree Heart Block
• If stable patient (B/P & LOC) - monitor
• If unstable patient & narrow complex (QRS)
– Atropine 0.5 mg rapid IVP
– May repeat every 3-5 minutes to max of 3mg
– TCP if Atropine not effective
• If unstable patient & wide complex (QRS)
– Begin TCP (Valium for comfort)
– If TCP ineffective, then Atropine 0.5 mg
repeated every 3-5 minutes to a max of 3 mg
“When they’re alive, give them 0.5”
Rhythm Identification
• What is this rhythm?
EMS Tx-Third Degree Heart
Block (Complete)
In bradycardias, always need to ask 2
questions:
#1 - Is the patient stable or unstable?
Stable needs monitoring
Unstable needs intervention
#2 - Is the QRS narrow or wide?
Narrow treated initially with Atropine
Wide treated initially with TCP
Rhythm Identification
• What is this rhythm?
• What intervention is necessary?
EMS Tx-Second Degree Type II
• If stable patient - monitor
• If unstable patient & narrow complex (QRS)
– Atropine 0.5 mg rapid IVP
– May repeat every 3-5 minutes to max of 3mg
– TCP if Atropine not effective
• If unstable patient & wide complex (QRS)
– Begin TCP (Valium for comfort)
– If TCP ineffective, then Atropine 0.5 mg
repeated every 3-5 minutes to a max of 3 mg
“When they’re alive, give them 0.5”
Rhythm Identification
• What is this rhythm?
• What intervention is necessary?
Second Degree Type I - Wenckebach
• If stable patient - monitor
• If unstable patient & narrow complex (QRS)
– Atropine 0.5 mg rapid IVP
– May repeat every 3-5 minutes to max of 3mg
– TCP if Atropine not effective
• If unstable patient & wide complex (QRS)
– Begin TCP (Valium for comfort)
– If TCP ineffective, then Atropine 0.5 mg
repeated every 3-5 minutes to a max of 3 mg
“When they’re alive, give them 0.5”
Rhythm Identification
• What is this rhythm (the patient has no
pulse)?
• What intervention is necessary?
There is no pulse!
EMS Tx - PEA (rate under 60)
• Emphasis will be on good quality CPR
• CPR is 30:2 (compressions to ventilations)
• After intubation, breaths delivered once every
6-8 seconds, compressor doesn’t stop
• Search for causes (6 H’s, 5 T’s) & treat them!
• Epinephrine 1:10,000 1 mg every 3-5 minutes
• If rate <60, Atropine 1 mg every 3-5 minutes
(max 3 mg)
• If rate >60, just Epinephrine & good CPR
Scenario #1
• EMS calls with report of a 56 year-old
female with left sided abdominal pain
• Based on the report, the ED MD informs
you to tell EMS they must transport this
patient to the closest facility.
• The patient is alert and oriented and
requests transport to a farther hospital
• Can the ED MD force EMS to transport this
patient to the closest facility?
Scenario #1
• A patient who is alert and oriented and can
understand the risks and benefits has the right to
request and expect transportation to the facility
of their choice
• EMS should have the patient sign the release for
not going to the closest facility
• Time should not be wasted in the field arguing
with a patient about the facility to transport to
• As in the ED, not all patients make the same
choice you would for healthcare issues but they
do have the right to make THEIR choice
Scenario #2
• EMS is on the scene with a patient who had
a diabetic reaction with a blood sugar
initially of 45. The current blood sugar is
now 80.
• EMS calls to inform the ED that they are
obtaining a release/refusal for further care
and transportation
• How is the ECRN to respond to this radio
call?
Scenario #2
• Verify if EMS needed any special orders
• Often times EMS calls in to document that
Medical Control was aware of the release
especially if there was something unusual
about the call
• Releases/refusals/AMA’s in the field can be
obtained in regards to assessment,
treatment, and/or transportation of the
patient
Scenario #3
• EMS calls in and reports that they have a
critical patient and will be providing an
abbreviated radio report
• What does it mean to receive an abbreviated
report and what information can you expect
to receive as the ECRN?
Scenario #3
• An abbreviated radio report (SOP page #4)
may be provided to Medical Control in
situations where manpower is limited and/or
the patient’s condition is critical
• Time in the field is more importantly spent
with all focus on caring for the patient; often
all available personnel need to be caring for
the patient and the driver needs to focus on
driving to get everyone to the hospital as safe
and fast as possible
Scenario #3
• Contents of an abbreviated radio report
– Identification of provider name, vehicle number and
receiving hospital
– Nature of situation and protocol being followed
– Age and sex of patient
– Chief complaint and brief history of present illness/injury
– Airway and vascular access status
– Current vital signs
– Major interventions completed or being attempted
– ETA to receiving hospital
• EMS to provide detailed information upon ED arrival