Download Curriculum Update: SOP Review Rhythm Review

Curriculum Update:
SOP and
Bradycardia Rhythm Review
Based on SOP’s March 2005
Condell Medical Center
EMS System
October 2006
Site Code #10-7200E-1206
S Hopkins, RN, BSN, EMT-P
Objectives
• Upon successful completion of this program,
the EMS provider should be able to:
– identify indications, contraindications, dosing,
special considerations, and side effects of
medications used in the Region X SOP
– participate in rhythm review
– state the indications and site of choice of the IO
needle
– participate in rhythm identification practice
– successfully complete the quiz with a score of
80% or greater
Introduction - Adult Intraosseous
(IO) Infusion
• Can be useful:
– when there is a need for IV access and an
IV cannot be established in 2 attempts or
90 seconds
• May be helpful to use immediately in cardiac
arrest or profound hypotension with altered
mental status
Adult IO Contraindications
• Fracture of tibia or femur (consider alternate
extremity)
• Infection at intended site
• Previous orthopedic procedure to the area (ie:
knee replacement, IO previous 480)
• Preexisting medical condition (ie: tumor near
site, peripheral vascular disease)
• Inability to locate landmarks (ie: significant
edema)
• Excessive tissue at site (ie: morbid obesity)
Adult IO Procedure
• BSI protection including face/eye shield
• Fill 10 ml syringe with normal saline.
• Prime connecting tubing (1 ml) leaving 9 ml
in syringe and leave syringe connected to
tubing
• Identify landmarks
– just medial to tibial tuberosity on flat portion of
proximal tibia (same site for pediatrics)
– FYI: intramedullary vessels do not collapse
even in critically ill patients
Adult IO Procedure cont’d
• Cleanse insertion site
• Prepare EZ-IO driver and needle set
• Stabilize leg with non-dominant hand
– do not place your hand under patient’s leg
• Insert EZ-IO needle at 900 angle
Adult IO Procedure cont’d
• Activate driver by depressing trigger on
handgrip while maintaining firm & steady
pressure on driver
– most insertions accomplished under 10 seconds
• Once decreased resistance is felt, or needle
flange touches skin (whichever is first),
release the trigger
• While stabilizing hub, remove driver from
needle set
Adult IO Procedure cont’d
• Remove stylet by rotating counterclockwise
– place stylet in sharps container
• Connect primed EZ-connect tubing
• Using syringe, flush with remaining 10 ml
normal saline
– observe for swelling or
extravasation around site
– to improve flow rate,
give 10 ml bolus
normal saline rapid IVP
Adult IO Procedure cont’d
• Confirm needle placement
– most reliable indicators:
• needle firmly in bone
• fluid infuses well
– inability to aspirate does not mean nonplacement
– if placement is in doubt, leave needle in
place with connecting tubing & syringe
attached and ED staff can reevaluate site
Adult IO Procedure cont’d
• Attach EZ-connect to IV tubing & begin
infusion
– any drug given IVP can be given IO
– dosages, onset, & peak concentrations virtually
identical to those given IVP
– IO route is preferred over ETT route
• Apply pressure to IV bag to facilitate flow
– flow rates will be slower than IV routes due to
anatomy of IO space
– pressure may be applied manually or with a
blood pressure cuff
Adult IO Procedure cont’d
• Secure tubing to leg
• Apply wristband supplied with equipment
– offers 24 hour hot line for questions
– reminds staff to remove EZ-IO within 24 hours
• Frequently reassess pressure to IV bag
• Monitor EZ-IO site and patient condition
– infection rates are low (0.6%)
– another EZ-IO may be used in same limb after 48
hours
– check calf area for swelling after any fluid bolus
Adult IO Procedure Patient Feedback
• “Pain” felt during insertion equivalent to
bumping shin on a table (5/10)
– lasted < 10 seconds
• Similar levels of pain felt
when IV infusions started at
max rates
– your patients will not be
conscious!
Dr. Miller, EZ-IO developer after
practice insertion of device
EZ-IO Device
• FYI:
– Same drill will eventually be used for
pediatric and adult insertion of IO device
– Needle size will change to adapt to
population receiving IO
– Hands-on practice will take place in
future CE
Electrical Conduction System
SA
AV node
Bundle of His
Right & Left
Bundle Branches
Purkinje Fibers
Sinus Bradycardia
• Rate: < 60 bpm
• Rhythm: regular
• P waves: positive, upright, rounded,
precede each QRS, all look relatively alike
• PR interval: 0.12 - 0.20 seconds; relatively
constant
• QRS: <0.12 seconds (unless intraventricular
conduction delay is present)
Atrioventricular (AV) Blocks
• Delay or interruption in impulse conduction
in AV node, bundle of His, or His-Purkinje
system
• Classified according to degree of block and
site of block
– PR interval is key in determining type of AV
block
– Width of QRS determines site of block
AV Blocks
• Clinical significance dependent on:
degree or severity of the block
rate of the escape pacemaker site
• ventricular site will be slower than a
junctional site
patient’s response to that ventricular rate
• evaluate level of
consciousness/responsiveness and
blood pressure
Second Degree AV Block
Wenckebach, Mobitz Type I
• Rate: atrial rate is greater than ventricular rate
• Rhythm: atrial rate regular (P to P marches
out); ventricular rate irregular (dropped QRS)
• P waves: P waves all uniform, not all P waves
followed by QRS
• PR interval: getting progressively longer until
there is a P wave without a QRS
• QRS: < 0.12 seconds
Second Degree AV Block
Classical, Mobitz Type II
• Rate: atrial rate greater than ventricular
• Rhythm: atrial regular (P’s to P’s march out);
ventricular regular if degree of block is
constant
• P waves: normal in appearance; not all
followed by QRS
• PR interval: constant for conducted beats
• QRS: < 0.12 seconds
3rd Degree Heart Block - Complete
• Rate: atrial rate greater than ventricular;
ventricular rate determined by site of escape
rhythm
• Rhythm: atrial regular (P’s to P’s march out);
ventricular regular but no relationship to atrial
• P waves: normal in appearance
• PR interval: none (no relationship between
atrial & ventricular rhythms
• QRS: narrow if junctional pacemaker site or
wide if ventricular pacemaker site
Helpful Tips
• Second degree Type I
– think Type I drops one
– Wenckebach “winks” when it drops one
• Second degree Type II
– think 2:1, 2:1, 2:1
– recognize the block can be variable or
something other than 2:1
• Third degree - complete
– think completely no relationship between atria
and ventricles
How Can I Tell What Block It Is?
Rhythm
Second degree
Type I –
Wenckebach
Second degree
Type II –
Classical
Third degree –
complete
PR interval
R-R interval
Irregular
Irregular
Regular
Regular
Irregular
Regular
Junctional Rhythms
• Rate: 40 - 60 bpm
• Rhythm: very regular
• P waves: may occur before, during, or after
QRS; if visible are inverted in lead II, III, &
AVF
• PR interval: if P wave present, usually
shortened (< 0.12 seconds)
• QRS: normally < 0.12 seconds, longer if
aberrantly conducted
Junctional Rhythms
Rate determines description:
Junctional escape rhythm rate is 40-60 bpm
Accelerated junctional rhythm rate is
61 - 100 bpm
Junctional tachycardia rate is over 100
Treatment/Interventions Bradycardia
• Guided by presence and degree of signs and
symptoms
• Atropine
– used to increase heart rate
– can increase rate of SA node discharge;
increase speed of conduction through AV node;
has little or no effect on contractility
– typical dose starts 0.5 mg IVP
– maximum dosage 3 mg IVP
Additional Treatment
• Transcutaneous pacing
– no response to doses of atropine
– unstable patient with a wide QRS
– set pacing at a rate of 80 beats per minute in the
demand mode
– start output (mA) at lowest setting possible and
increase until capture
– Valium 2 mg IVP (increments to 10 mg) should
be given to help with the chest discomfort
Patient Unresponsive To Therapy
• Consider the patient may be in cardiogenic shock
• Consider fluid challenge 200 ml; may repeat once
• Evaluate breath sounds before & after fluid
• Dopamine drip to maintain B/P >100
• Start dopamine minidrip at 5 mcg/kg/min
Tip - quick drip calculation: take pt’s weight in
pounds, take 1st 2 numbers, subtract 2. This is
drip factor to start with (ie: pt weight 210#;
21 - 2 = 19; start drip at 19 minidrips/minute)
What Is This Rhythm?
• Sinus bradycardia
• At this rate the patient is expected to be
symptomatic
• Treatment if symptomatic?
• Atropine for narrow complex QRS; TCP if QRS
wide
What Is This Rhythm?
• Second degree Type I - Wenckebach
• Treatment usually not necessary as heart rate is
usually near lower limit of 50’s - 60’s and patient
is rarely symptomatic
• Monitoring is required for deterioration
What Is This Rhythm?
• Second degree Type II - Classical (narrow
complex)
• Overall ventricular rate is most often slow causing
the patient to be symptomatic and requiring
therapy
What Is This Rhythm?
• Second degree Type II - Classical
• Wide QRS indicates the origin of the escape
pacemaker site is low down in the conduction
system
• TCP should be used ASAP if patient symptomatic
What Is This Rhythm?
• Third degree heart block - complete
• P to P’s are regular; R to R’s are regular
• There is no relationship between the atria and
ventricles (no pattern or consistency with PR
interval)
What Is This Rhythm?
• Third degree - complete heart block with a wide
QRS complex
• Treatment includes avoiding atropine and starting
with TCP
What Is This Rhythm?
• Junctional rhythm (P waves inverted)
• Inherent rate of AV node is 40 -60 bpm
• Treatment is based on symptoms and tolerance of
patient
What Is This Rhythm?
What Is This Rhythm?
• Second degree Type I - Wenckebach
• For some patients, this may be their normal
rhythm. For others, they may go back and forth
between sinus rhythm and second degree heart
block Type I without signs or symptoms
What Is This Rhythm?
• Sinus bradycardia with wide QRS (bundle branch
block pattern)
• Need to determine if patient is symptomatic or not
before deciding on interventions needed
What Is This Rhythm?
• Third degree heart block - complete
• With this appearance and heart rate, patient more
than likely will be symptomatic
• If narrow QRS, start with atropine
• If wide QRS, patient needs TCP (omit atropine)
Implanted pacemaker
Paced Rhythm - 100% Capture
What Is This Rhythm?
• Paced rhythm with single failure to capture
• Pacemaker wires may need to be repositioned at
the hospital
• Carefully monitor EKG for further loss of capture
Revised AHA CPR Guidelines
• The message:
– focus is “back to basics”
– push harder, push faster
• 30:2 for adult 1 & 2 man; child & infant 1 man CPR
• 15:2 for child & infant 2 man CPR
• rate of 100 compressions/minute
• perform 5 cycles of 30:2 CPR in 2 minutes and then
prepare to defibrillate if needed
• switch CPR roles every 2 minutes due to exhaustion
(if the compressor is tired, CPR will be sloppy and
will not be effective)
– minimize CPR interruptions to < 10 seconds
CPR Changes cont’d
– perform CPR if there is any delay while charging
defibrillator
– do not perform pulse checks unless you observe a
rhythm that should provide perfusion
– after defibrillation immediately resume CPR
• do not stop to perform a rhythm check
– ventilations over 1 second
• once every 5-6 seconds via BVM to mouth
• once every 6-8 seconds with advanced airway in
place (ETT, combitube, LMA)
– IV/IO drug route preferred over ETT route
Review SOG’s
• DNR status
– properly completed form must be present with patient
– can recognize old orange form or new watermelon
colored form
– can be a reproduction on any color paper
• Closest hospital
– patient choice when possible & allowable
– clinical condition of patient dictating destination
• lack of airway
• unstable, near arrest condition
• psych patient with no preexisting relationship
elsewhere
Cardiac Protocol Review
• Acute Coronary Syndrome
– chew aspirin to enhance absorption
• if patient reliable and took daily dose, do not
need to repeat dose; inform medical control; if
aspirin not given for any reason, document why
– if patient < 35, give aspirin and then confer with
medical control before giving nitroglycerin or
morphine
– 12 lead if treating patient for acute coronary
syndrome
• inform ED you are sending 12 lead
• Tachycardia
– determine if the patient is stable or unstable
• evaluate blood pressure and level of
consciousness
• if unstable needs cardioversion (start at 100 j)
• if stable, determine if QRS is narrow (think
adenosine) or wide (think lidocaine)
• PEA/asystole
– think & treat for potential causes (H’s & T’s)
– PEA: epi 1 mg; if rate is <60 atropine 1mg (max
3 mg)
– asystole: epi 1 mg; atropine 1 mg (max 3mg)
Stroke/Brain Attack
• Screen all patients for time of onset of
symptoms
– assessment & diagnostics must be completed and
drug intervention must be started within 3 hours of
onset (>3 hours increases risk of intracranial bleed
• Therefore, the most important question is:
“What time did your symptoms
start?”
Cincinnati Prehospital Stroke Scale
Facial droop
– ask patient to smile, big enough to show their teeth
– watch for droop and record as right/left sided
droop or no droop
Arm drift
– ask patient to close their eyes, hold arms out in
front, palms up, for 10 seconds
– watch for right/left drift or none
Abnormal speech
– abnormal is slurring words, using wrong words, or
inability to speak
In-Field Spinal Clearance
• A  reliable patient  without signs or
symptoms of neck/spine injury and 
negative mechanism of injury does not
require full spinal immobilization
• Document findings to support decision to
not immobilize
• When in doubt, fully immobilize
In-Field Spinal Clearance Criteria
Positive mechanism of injury - immobilize
–
–
–
–
–
–
–
–
–
–
high velocity MVC >40 mph
unrestrained occupant in MVC
passenger compartment intrusion >12”
ejection from vehicle
rollover MVC
motorcycle collision >20 mph
death in same vehicle
pedestrian struck by vehicle
falls >2 times patient height
diving injury
In-Field Spinal Clearance
Positive signs & symptoms
– pain in neck or spine
– tenderness/deformity of neck or spine upon
palpation
– paralysis or abnormal motor exam
– paresthesia in extremities
– abnormal response to painful stimuli
For the presence of any above noted signs
and/or symptoms, or gut instinct, the patient
needs full spinal immobilization
In-Field Spinal Clearance
Patient reliability questionable
–
–
–
–
signs of intoxication
abnormal mental status
communication difficulty
abnormal stress reaction
• ie: person extremely upset over the incident
If patient not reliable, full spinal
immobilization required
Interventions - Traumatic Injuries
Tension pneumothorax
– needle decompression - 2nd or 3rd intercostal space
midline of the clavicle, over the top of the rib
Sucking chest wounds
– occlusive dressing secured on 3 sides
– watch for development of a tension pneumothorax
• lift edge of dressing to burp during exhalation
Fluid resuscitation
– 20 ml/kg bolus normal saline
• adult reevaluate every 200 ml
• peds patient maximum of 3 boluses (60 ml/kg)
Did You Remember?
• What do the drugs for conscious sedation do?
Lidocaine for head insult (trauma or medical)
• prevents the cough reflex (coughing would raise
intrathoracic pressures which would transmit to
the brain and raise intracranial pressures)
Morphine - reduce anxiety & pain; facilitate a
response to versed
Versed - relax & sedate patient; act as amnesic
Benzocaine - eliminate gag reflex
• to test for gag reflex in unconscious patient, stroke
eyelashes - if blink reflex still present, patient still
has gag reflex
• use short 1-2 second spray to back of throat
• What drugs are good diagnostic tools to use for
unknown unconscious person?
Dextrose if glucose < 60
If glucagon given 1st and then IV established,
reassess glucose level and can give D50 if needed
Narcan 2 mg IVP
• useful in altered level of consciousness (ie: to
wake a patient up) and known/suspected narcotic
overdose (to improve ventilation depth and rate)
• if you have to chase a patient around the room to
administer narcan, then they don’t need narcan
yet
• When does CPAP get initiated?
Acute pulmonary edema, when patient remains
alert and cooperative, blood pressure remains >90
• When would CPAP need to be discontinued?
Blood pressure drops below 90
At any time the patient deteriorates further
• Diabetic emergencies
Hypoglycemic needs glucose (sugar) to replace
depleted stores
• brain most sensitive organ to low glucose levels
Diabetic ketoacidosis (DKA) (glucose >200) is
dehydrated and needs fluid replacement
• Allergic reaction/Anaphylactic shock
Simple (hives, itching, rash), stable
• Benadryl 25 mg slow IVP or IM
Simple with airway involvement
• Epinephrine 1:1000 0.3 mg SQ
• Bendadryl 50 mg slow IVP or IM
• If wheezing, albuterol 2.5 mg/3ml nebulizer
Unstable (hemodynamically) with anaphylactic
shock
• IV wide open
• Epinephrine 1:1000 0.5 mg IM (more
predictable absorption than SQ in shock)
• Heat emergencies
Heat cramps - do not massage extremities
Heat exhaustion - perspire, dizzy, headache
• IV fluid challenge
• begin gradual cooling
Classic heat stroke - hot, dry skin; altered level of
consciousness
• IV fluid challenge
• rapid cooling (wet, cool towels; cold paks; fan)
Exertional heat stroke - damp skin from activity
just performed (ie: marathon, construction worker)
• IV fluid challenge
• rapid cooling (wet, cool towels; cold paks; fan)
• Hypothermia
Frostbite
• rapidly rewarm (warm water, hot paks)
Systemic hypothermia
• hot paks
• If no pulse and extremities stiff (cannot be
flexed), limit defib attempts to 1st round &
withhold IV and meds; perform CPR during
transport
• If no pulse and extremities can be flexed,
extend medications to longest limit between
doses
• ie: every 5 minutes versus 3 minutes
• Burns - Morphine 2 mg IVP for pain control
Electrical
• dry, sterile dressing; EKG monitoring
Chemical
• brush dry chemical off before irrigating
• consider need for HAZMAT team
Inhalation
• O2 100% via nonrebreather or assist with BVM
Thermal
• Superficial (1st degree) - moist saline dressings
• Partial thickness (2nd degree) - dry sterile dressing,
transport pt covered with sterile sheet
• Full thickness (3rd degree) - dry sterile dressing,
transport pt covered with sterile sheet
OB Complications
• Placenta previa
– placenta implantation in lower part of uterus
partially or completely over cervical opening
– painless, bright red vaginal bleeding
• Abruptio placenta
– premature separation of placenta from uterine wall
– trapped blood loss in uterus; uterus firm & painful
– increased mortality rate mother & fetus
Treatment aimed at repeat assessment and
monitoring for & treating shock
Transport with patient lying/tilted left
OB Complications
• Hypertensive disorders of pregnancy have an
unknown cause, generally occur in 1st pregnancy,
and often near term
– signs & symptoms preeclampsia:
• headache, confusion
• blurred or double
• nausea & vomiting
vision
• protein spilled in urine
• hypertension
• excessive retention of fluid
• epigastric pain
– signs & symptoms ecclampsia - same as above with the
addition of seizures
• treat seizure activity with valium (crosses placenta)
OB Complications
• Supine hypotensive disorder
– heavy weight of uterus, esp after 5 months, may
put pressure on the inferior cava
– blood flow returning to the heart would be
diminished
– patient may complain of dizziness & be
hypotensive
Transport patient laying or tilted left especially after the 5th month
OB Complications
• Nuchal cord - cord around infant neck
– attempt to slip cord over the head
– if cord cannot be
moved, clamp & cut
cord now
– have mother breath
through contractions
to avoid her trying to
push during the
emergency
Newborn Inverted Pyramid
Pediatric Critical Conditions
• Glucose level < 60
– child > 1: D 25%
– child <1: D 12.5% (equal parts D 25% & normal
saline for dilution)
• Allergic reactions
– local: apply ice
– mild resp distress: epi 1:1000 sq 0.01 mg/kg (max
0.3 mg per single dose); albuterol 2.5 mg neb
– severe compromise: epi 1:1000 sq 0.01 mg/kg
(max 0.3 mg per single dose); when IV/IO
established, epi 1:10,000 0.01 mg/kg; fluid bolus
20 ml/kg, albuterol 2.5 mg neb for wheezing
Pediatric Critical Conditions
• Bradyarrhythmias
– Very different approach than for adults
– CPR if heart rate < 60 and poor systemic
perfusion
– Epi 1:10,000 IVP/IO or epi 1:1000 if ETT
– Atropine IVP/IO
• Peds arrest
– defib 2j/kg, then repeated at 4j/kg
– Drugs: epi 1:10,000 IVP/IO
lidocaine IVP/IO
Case Review: What Is This
Rhythm?
• Sinus bradycardia
• When is treatment required?
• If patient is symptomatic (decreased level of
consciousness, hypotensive)
What Is This Rhythm?
• Second degree Type II - Classical
• Patients will be symptomatic due to the slowed
ventricular heart rate
• Don’t assume symptoms but evaluate each patient
individually for their own threshold of tolerance
What Is This Rhythm?
• Accelerated junctional rhythm
• When is treatment indicated?
• When patient is symptomatic (decreased level of
consciousness and hypotensive) - doubtful this
patient would be symptomatic at rate of 70
• Treatment would be atropine if QRS is narrow
What Is This Rhythm?
• Paced rhythm - 100% capture; rate 75 beats per
minute
• Typical presentation of ventricular pacing wire
What Is This Rhythm?
• Sinus bradycardia
• Is treatment necessary at a rate of 50 beats per
minute?
• Treatment/interventions depend on symptoms and
tolerance of patient
What Is This Rhythm?
• Junctional escape rhythm with bundle branch
block pattern (wide QRS) or possibly a ventricular
escape rhythm
• At this rate and EKG appearance, the patient will
most likely be symptomatic and in need of
aggressive support, possibly CPR if in PEA
Case Review What Is This
Rhythm?
• Junctional rhythm
• Rate 40-60 beats per minute; no P wave activity
What Is This Rhythm?
• Second degree Type II - Classical
• Consistent PR interval when present, more P
waves than QRS complexes
What Is This Rhythm?
• Second degree Type I - Wenckebach
• PR interval gets progressively longer until there is
a dropped QRS
• Overall heart rate adequate and patient does not
need therapy
What Is This Rhythm?
• Accelerated junctional rhythm
What Is This Rhythm?
• Third degree heart block - complete
What Is This Rhythm?
• Third degree heart block - complete
• The first 2 P waves are visible; the last 2 are
buried in the wide QRS complexes