Download CE Behavioral Emergencies, Bariatric Patients, Autism, VADs and

May 2016 CMC EMS CE
Behavioral Emergencies,
Bariatric Patients, Autism,
VAD’s, and Life Vest
Prepared by:Deborah Semenek RN, EMT-P
Mark Dzwonkiewicz FP-C, LI
Elizabeth Peaslee RN
1
Objectives
Upon successful completion of this module, the EMS provider will be
able to:
1. Examine the differences in behavioral health diagnoses.
2. Review how to interact, de-escalate and treat patients with psychiatric
disease.
3. Examine differences in patient care approaches when caring for the
bariatric patient.
4. Review the patient population utilizing a VAD to support heart function.
5. Review care and transportation issues related to the patient with a VAD.
6. Review and discuss the use and care of a patient with a Life Vest.
7. Discover alterations in patient care in the environment of the patient
with autism.
8. Actively participate in review of selected Region X SOP’s related to the
topic presented.
9. Actively participate in case scenario discussion.
10. Successfully complete the post quiz with a score of 80% or better.
2

Behavioral Emergencies
•
Behavior- a persons observable conduct and activity
•
Behavioral Emergency- A situation in which the patient’s
behavior becomes unusual, bizarre, threatening and/or
dangerous that another person takes notice.
•
Factors that may indicate behavioral emergency….
•
Core life function disruption
•
Eating, sleeping, etc.
•
Threat to ones self or others
•
Deviation from societal norms
3
Pathophysiology
•
•
•
Up to 20% of the population has some form of mental health problems
Most are cared for in outpatient centers
Common reason for EMS involvement is due to medication
noncompliance
4
Causes of Behavioral
Emergencies
•
Biological
•
Results from disease process
•
•
Structural changes
•
•
Tumors or infections
Abuse of drugs and alcohol
Never assume a patient with AMS has a
psychological condition until all possible medical
conditions or substance abuses are ruled out.
5
Psychosocial
•
Related to personality style, unresolved
conflicts or crisis management methods
•
Examples….
•
Traumatic childhood event
•
Development of peer pressure
•
Dysfunctional families
•
Lack of parental support
•
Abusive parents
6
Sociocultural
•
Related to patients actions and interactions with
society
•
Effect patient social space, social isolation or
otherwise impact patient socialization
•
•
Relationships, support system, social habits,
social skills and values
Caused by profound events
•
Rape, assault, witness to victimization of
others, death of a loved one, acts of violence
7
AMS SOP
Consider Etiology
(Diabetes, drug overdose,
Poisoning, stroke,
Alcohol related)
Adult Routine Medical Care
Immobilize C-spine as indicated
Obtain blood glucose and record
If <60 administer Dextrose 50% 50 mL IVP/IO
-orGlucagon 1 mg IM/IN
8
AMS SOP cont.
If patient not alert/decreased respiration/
suspected narcotic overdose
Narcan 2mg IN/IVP/IO every 5 minutes as needed to
max dose of 10mg
•
Attempt to ID substance involved
•
Bring any containers found to hospital, so long as
they aren’t a safety risk
•
Consider restraints prior to administration of
Narcan
9
Remember Etiology
A-
Acidosis,
Alcohol
E- Epilepsey
I- Infection
O- Overdose
U- Uremia
T-
Trauma,
Tumor
I- Insulin
P- Psychosis
S- Stroke
10
Arrive on Scene
•
Scene safety and BSI
•
Call law enforcement, if necessary
•
•
Begin verbal report with the patient
Determine and document if patient is a threat to
themselves or others
•
Examine the environment for potential threats
•
If suicidal, patient can not be left alone. At
least one EMS provider should remain with the
patient.
11
Verbal De-escalation
•
Attempt with all patients
•
Should be first method to attempt to calm aggressive
patient
•
Safest because it requires no physical contact
•
Be honest and straight-forward with a friendly tone
•
Avoid direct eye contact or invading patient’s personal
space which may increase stress and anxiety
•
Can diffuse a situation and prevent further escalation
and/or the need for physical restraints
12
Restraints
•
Last resort
•
Two types- locked and soft
•
Suggested to have 5 people for safest application
•
Make every attempt to avoid injury to patient
•
Never transport patient in prone position
•
Document:
•
•
Reason for restraint, type and location of
restraint, time of restraints
Assess distal SMV’s
13
Consider Medical
Etiology
•
•
•
•
•
•
Hypoxia
Substance Abuse/Overdose
Excited Delirium/Hyperthermia
Neurologic Disease (CVA, Intracerebral Bleed, etc.)
Metabolic Problems (Hypoglycemia)
Continue routine medical care for adult or pediatric
patient
14
Medications Needed
•
Contact medical control for pediatric
patients
•
In patient with severe anxiety or agitation:
•
•
Versed 2mg IN
•
May repeat every 2 minutes until desired
results to max of 10mg
If additional medication needed:
•
Valium 5 mg IVP over 2 minutes, may
repeat up to 10mg or Valium 10mg IM
15
Petition
Legal documentation to transport patient to the
hospital from the scene with or without patient
consent
• Assist keeping patient in hospital throughout
evaluation
• Family members, police, EMS or bystanders can
complete petition
• Petition does not guarantee a patient will be
committed
•
16
Behavioral Emergency
Notes
•
•
•
All region X hospitals can accept any psych
patient
Transport all medication or substance bottles
safely with patient
Remember mentally ill patients are more
aware of their surroundings than they appear,
so be caerful what is said around them
17
Cognitive Disorders
•
Organic causes such as brain injury or
disease
•
Caused by physical or chemical injuries
•
Delirium
•
Dementia
18
Delirium
•
Rapid onset of widespread disorganized thoughts
(hours or days)
•
Symptoms:
•
•
Causes:
•
•
Inattention, memory impairment,
disorientation and general clouding of the mind
Medical conditions, intoxication or withdrawal
Confusion is a hallmark sign
19
Dementia
•
Develops over months and is usually irreversible
•
Several possible medical etiology
•
•
Involves…
•
•
Alzheimer’s, vascular problems, AIDS, head
trauma, Parkinson’s and substance abuse
Memory, cognitive, and pervasive impairments
Be supportive
20
Schizophrenia
•
Effects an estimated 1% of the U.S. population
•
Hallmark sign is a significant change in behavior
and loss of contact with reality
•
May live in their “own world”
•
Symptoms:
•
•
•
Hallucinations, delusions, and depression
Symptoms will cause social or occupational
dysfunction
Usually diagnosed in early adulthood
21
Anxiety Disorders
•
Characterized by dominating apprehension and
fear
•
Affects approximately 2-4% of the population
•
Uneasiness, discomfort, nervousness and
restlessness
•
Panic disorder, phobia, and post-traumatic
stress syndrome
22
Panic Attack
•
Recurrent, extreme periods of anxiety resulting in great
emotional distress
•
Acute in nature and unprovoked
•
Usually peaks in 10 minutes and dissipates in 1 hour
•
May present cardiac or respiratory in nature, so EMS must rule
out both possibilities
•
Symptoms:
•
•
Palpitations, sweating, trembling, shortness of breath, chest
pain or discomfort, nausea, dizziness, loss of control, fear of
dying, numbness or tingling sensation and/or chills or hot
flashes
Management:
•
Supportive care
23
Phobias
•
A fear that becomes excessive and interferes with
functioning
•
The fear is considered intense and irrational
•
Exposure to fear will induce anxiety or panic
attack
•
Manage patients by being supportive
24
Post-Traumatic Stress
•
A reaction to an extreme, usually life-threatening
stressor
•
Natural disaster, victimization (rape, etc.), and
emotionally taxing situations
•
Will avoid similar situations
•
Recurrent intrusive thoughts
•
Depression
•
Sleep disturbances
•
Nightmares
•
Manage patient with respect, empathy, and support
25
Mood Disorders
•
Pervasive and sustained emotion that colors a
person’s perception of the world
•
Depression
•
Bipolar Disorder
26
Depression
•
Profound sadness or feeling of melancholy
•
Most prevalent psychiatric condition
•
Major depressive disorder
•
•
Depression that is prolonged or severe
Symptoms:
•
Depressed most of the day
•
Decreased interest in pleasure
•
Weight loss
•
Insomnia or hypersomnia
•
Lack of concentration
•
Thoughts of death
27
Bipolar Disorders
•
One or more manic episodes with or without subsequent or
alternating periods of depression
•
Begins suddenly and escalates rapidly over a few days
•
Develops in adolescence or early adulthood
•
Symptoms:
•
Increased self-esteem
•
Less need for sleep
•
More talking or pressure to keep talking
•
Flight of ideas
•
Distractibility
•
Increased goal-directed activity
•
Delusional thoughts
28
Substance Disorders
•
Substance abuse is a common disorder
•
EMS should rule out as a possibility when a patient
is experiencing psychiatric or behavioral
symptoms
•
May present as depression, psychosis, or delirium
•
Serious condition
•
Patients may present ill from addiction or
withdrawal from the substance
29
Withdrawal from Alcohol
•
Happens from abrupt discontinuation of, or after
prolonged use of, or from rapid fall in blood
alcohol level
•
Symptoms can occur several hours after last drink
and can last up to 5-7 days
•
Seizures can occur within the first 24-36 hours
after last drink
30
Withdrawal Signs and
Symptoms
•
•
•
•
•
•
•
•
•
•
Tremors of the hands, tongue, and eyelids
Nausea and vomiting
General weakness
Tachycardia
Sweating
Hypertension
Orthostatic hypotension
Anxiety, irritability or depressed mood
Hallucinations
Poor sleep
31
Delirium Tremens
•
Usually develop in second or third day of withdrawal
•
Symptoms:
•
Decreased level of consciousness
•
Hallucinations
•
Misinterpretation of events
•
Seizures
•
Significant mortality rates
•
Treatment with benzodiazepines can help prevent seizures
32
Excited Delirium
•
Can be caused by drug intoxication, psychotic illness or both
•
Symptoms:
•
Abnormal pain tolerance, tachycardia, sweating, agitation,
skin that feels hot, non-compliance with police, lack of
tiring, unusual strength, inappropriate clothing
•
Difficult to diagnose
•
Be aware of the patient who becomes suddenly tranquil after
frenzied activity because this is usually followed by cardiac
collapse and death
•
Always consider if a patient needs to be restrained
•
Allowing a patient to struggle against restraints increases risk of
death
33
Bariatric
Patient
•
Most common reason
EMS is toned out is
for undifferentiated
abdominal pain
•
Always assure scene
safety and BSI
34
Assess Patient Airway
•
•
•
•
•
Assess for patency
Morbidly obese patients have excessive skin
and adipose tissue around their cheeks,
lower jaw, and thorax which can place
extra pressure on the tongue and airway
Increased oxygen consumption
Increased carbon dioxide production
Excess metabolic activity
35
Assessing Breathing
•
•
•
•
•
Decreased lung capacity from decreased chest
wall compliance and increased abdominal cavity
contents
Makes bariatric patients at risk for hypoxemia and
hypercarbia
Gives patients less respiratory reserve
Prepare for rapid decline
Breath sounds may be difficult to hear due to
increased amount of adipose tissue
36
Ventilation Complications
•
If patient has no c-spine injury, place the patient supine and use
blankets to place under head, neck and shoulders to place in a “ramp
position”
•
Utilize oral and nasal airways
•
Don’t overestimate lung volume due to patient size
•
When possible use two person technique with a jaw thrust for BVM
ventilation
•
If intubation needed….
•
Prepare for difficult attempt in patients with sleep apnea
•
Sedatives given can completely occlude airway with tongue
•
Use capnography for tube confirmation due to difficulty in
auscultation related to increased adipose tissue
37
Ramp Position
38
Assessing Circulation
•
Increased stress on the heart
•
Increased cardiac output even at rest due to the need for
extra tissue profusion
•
Increased basal heart rate
•
ECG may be less reliable due to the distance of the
electrodes to the heart
•
Increased prevalence of heart disease in a younger
demographic
•
If the need for immobilization arises, use caution so the
collar is not so tight it restricts blood flow to major vessels
in the neck
39
Obtaining History
•
Per normal protocol, like with any patient
•
Signs and symptoms of complaint
•
Allergies
•
Medications
•
Past medical history
•
Prepare for increased number of medical
conditions
•
DM, HTN, hyperlipidemia, increased vascular
disease, stroke, cardiac disease, CHF,
peripheral edema, and ulcerations of the skin
40
Bariatric Surgery
•
To include gastric bypass, Lap-Band and gastric
sleeve can result in early and late complications
•
Early- within the first month s/p surgery
•
•
Think DVT, PE, wound infection, sepsis or GI
bleed
Late- after the first month s/p surgery
•
Think strictures, hernia or hardware
complications
•
Gastric bypass has increased incident of ulcers
•
Lap-Band has increased hardware malfunctions
41
Bariatric Surgery
Gastric Bypass
Lap-Band
42
Abdominal Assessment
Exam will be complicated by loss of
anatomical landmarks
• Palpation of deep structures will be
limited due to amount of adipose
tissue
• Increased adipose tissue also limits
Cullen’s and Grey Turnner’s signs
•
43
Autism
•
Neurological disorder
typically appearing in the
first three years of life
•
Affects the area of brain
function responsible for
development of
communication and social
interaction
•
1 in 110 children, more males
than females
•
No known cause or cure
•
No obvious physical markers
44
Autism
•
•
Low-functioning
•
Difficulty with basic life skills
•
Usually a caregiver is with the patient at all times
High-functioning
•
•
Live semi- or fully-independent lives
Affects sensory responses
•
Manage environment safely
•
May not react well to change while en-route
•
May have “fight or flight” when approached
•
Decrease as much stimulation as possible
45
Autism Signs and
Symptoms
•
Non-verbal or limited speech
•
Avoid eye contact
•
Prefer to be alone
•
Difficulty expressing needs
•
Difficulty interacting with others
•
Avoids touch
•
Sustained unusual repetitive actions
•
Laugh or giggle inappropriately
•
Trouble with correct speech volume
46
Common Reasons for 911
•
Patient or caregiver action may be misinterpreted as
assault
•
Unusual behavior in the community setting
•
Escalating behavior
•
•
Rocking, pacing, grunting, noisemaking, running into
walls, head banging, or hiding
Dangerous wandering
•
May not respond to the calling of their name
•
May not want to seek help
47
Scene Safety
•
Make sure patient is unarmed and at a safe
distance
•
Patient’s body language my show you what is
stressing them out
•
May suddenly invade your personal space
•
To move patient, you may need to quickly wrap
them with a blanket with their arms at their sides
•
EMS must always stay with patient
48
Interaction
Use direct and short phrases
• Avoid figurative expression
•
•
•
•
•
•
•
Allow for delayed responses, your interview will take
longer
Talk calmly and softly
Become familiar with patient communication style (ask
caregiver)
Model calm body language
Model behavior you want your patient to display
Patient may repeat your words or phrases, body language
or emotional state
49
De-escalation
•
If patient is unarmed and has geographic
containment, allow patient time to self deescalate
•
Seek information and help from parent or
caregiver about techniques that help the patient
•
Don’t attempt to stop repetitive behaviors
•
Remain alert for the possibility of outbursts
50
Restraints
•
May still have to restrain patient after all other
options have been exhausted
•
If absolutely necessary, approach the patient from
the side
•
After restrained, turn patient on their side to
allow normal breathing
•
Monitor patient to prevent further trauma
•
Continue to communicate, de-escalate and use
calming techniques with the patient
51
Suicide in Autism
•
Common especially among high-functioning
autistics
•
They miss social cues
•
Lack the ability and experience to deal with
school
•
Become emotional wrecks by middle school,
putting them at high risk for suicide
52
EMS Tips
•
Allow for delayed response
•
Difficulty adapting to change
•
Take everything literally
•
Person may not show any signs of pain
•
Evaluate for pain with a thorough secondary exam
•
Avoid touching
•
Explain all medical procedures, they will be more likely to
allow it
•
Metal, plastic, or other objects of different temperatures
can feel like pinpricks to patient
53
EMS Tips (con’t)
•
Equipment should fit snugly
•
Allow patient to bring security item
•
Remember ambos are loud. Reduce as much secondary
noise as possible including air blowing on the patient
•
May flee due to sensory overload
•
Constant patience and reassurance
•
Behaviors will challenge your training and instincts
•
Be aware of associated medical conditions
54
VAD’s

Ventricular Assist Device

Treatment for advanced
heart failure

Surgical process to
implant

Assists heart function by
circulating the blood

A continuous flow pump

Increases patient energy
level
55
Indications
•
Patient in class 3 or 4 heart failure while at rest or in
cardiogenic shock
•
Short term
•
•
Long term
•
•
Patient on transplant list but very sick
Not a transplant candidate
Bridge to Recovery
•
Treating cardiogenic shock
•
Unable to come off heart-lung machine s/p surgery
56
Usual Demographics

35-65 years old

Multiple medical
problems

Death is primarily
from non-VAD related
causes

Without transplant
survival rate is about
4-5 years
57
Living with the VAD
•
May return to daily activities with few limitations
•
Patients look normal and healthy
•
They have increased energy
•
No travel restrictions
•
Must avoid contact sports and water activities
58
Risks To Patient
•
Bleeding
•
•
All VAD patients are on prophylactic anticoagulants
which increase a patients risk for bleeding
Infection
•
Direct access portal of entry to heart
•
Stoke
•
Device malfunction
•
Death
59
VAD Function

Inflow portion
surgically connected
to apex of left
ventricle

Outflow portion
surgically connected
to ascending aorta

Right side of heart can
still function normally
60
Components of VAD

Surgically implanted in body
with communication to the
outside of the body

Pump


Inside body and delivers
blood to aorta

Take over the work of left
ventricle
Driveline

Inside and outside of body

Communicates with the
pump

Don’t cut or disconnect,
pump will stop
61
Components (con’t)
•
•
•
System Controller
•
Outside of the body
•
Computer that controls all functions of the VAD
•
“Brain”
Batteries
•
Outside the body
•
External power source
•
Last 4-12 hours
•
Can press battery button to determine the charge level
AC/wall power
62
•
NEVER remove both power sources at the same time
Care of the Driveline
•
A wire that exists the body
•
High risk for infection
•
Always stays covered with a sterile dressing
•
Direct portal to the heart
•
DO NOT remove the dressing
•
DO NOT pull or tug on the driveline
•
DO NOT disconnect from battery pack
63
Back Up Equipment

All patients have a travel
bag

This bag contains:


Extra system controller

Extra set of charged
batteries

AC/ wall plug

Cell phone with appropriate
phone numbers
MUST come with the
patient for transport
64
VAD Readings
•
•
•
Flow
•
Amount of blood flowing through the pump
•
Measured in L/min
•
AKA: cardiac output
Speed
•
A set number
•
Shows how fast the pump is running
PI
•
•
Power
•
•
Volume in left ventricle
Amount of energy in WATTS to maintain speed
Like an extra set of vitals
65
Patient Assessment
•
Pulses may or may not be present
•
Differs from patient to patient
•
Use a stethoscope over lower part of heart to
listen for the “hmmm” sound of the VAD
working
•
May only obtain blood pressure if patient has
pulses
•
If no pulses, a Doppler is needed to assess
pressure
•
Pulse ox may be unreliable
66
Patient Assessment
•
Neurologic
•
Increased risk for stroke due to anticoagulation
•
Glucose levels are unaffected
•
Skin parameters stay the same
•
VAD doesn’t affect ECG
•
Electrical activity continues in the heart with
or without capture
•
PEA
67
VADs & Anticoagulation

All VAD patients are anticoagulated

Increased risk for bleeding

Take all bleeding
precautions

Coumadin/warfarin is the
only medication approved
for all devices
68
EMS Arrest Interventions
•
Listen for the “hmmm” of the VAD, if you hear it, no need
for compressions. VAD is circulating the blood.
•
If no “hmmm”, begin CPR
•
•
•
•
Don’t worry about dislodging equipment because if
nothing is done patient has no survival chance
Cardiac medications
•
Can be given, but will have different levels of
effectiveness
•
Discuss Dopamine with medical control prior to use
90-95% of patients have ICD’s, but if need arises EMS may
use their defibrillator
Mast arrests are not VAD failures but some other etiology
69
Emergency Action
•
VAD stops functioning, must be restored or patient
will die
•
Check driveline connection to controller
•
Check power lead connection to controller
•
Check power source
•
Replace system controller
70
VAD Do’s and Do Not’s
Do

Follow CAB’s

Listen to family

Bring all VAD equipment
to the hospital

Keep patient on 2 good
power sources at all times
Do Not

Never disconnect driveline
from controller

Never disconnect both
power sources at the
same time

Never expose VAD to
water

Don’t open or view
sterile exit site
71
EMS Tips
•
Follow BLS protocol
•
Make sure all connections are connected
•
Verify power
•
Listen to patient’s family
•
Bring all equipment to hospital in the ambulance
•
A DNR is not required for a VAD patient
72
Zoll Life
Vest
•
First wearable
defibrillator
•
98% first shock efficacy
rate
73
Zoll Life Vest
•
•
•
•
•
Wearable defibrillator is a treatment option for sudden cardiac arrest
Worn on the outside of the body
Continuously monitors patient with dry non-adhesive electrodes
If life-threatening rhythm is detected the device will alert patient
prior to delivering shock to give the conscious patient a chance to turn
the shock off
If the patient is unconscious, the device will release a blue gel over
the electrodes prior to delivering shock
74
Life Vest and EMS
•
Standard evaluation and treatment
•
Begin CPR if devise is not saying
•
“Press the response button”
•
“Electric shock possible. Do not touch patient”
•
“Bystanders do not interfere.”
•
May replace with external defibrillator after removing Life Vest
•
To remove
•
First pull battery out
•
Then remove vest
75
Zoll Life Vest
76
Case Scenario #1
You arrive on scene for a patient who “under the weather”. They are responsive,
GCS 15, warm and dry, with a capillary refill less than 2 seconds. They have a
VAD device.
How will the VAD influence your ability to complete the assessment of vital signs
and ECG for the patient?
Patient may or may not have pulses
No pulses means no blood pressure
The ECG with remain unaffected
77
Case Scenario #2
Your patient is suffering from severe anxiety.
What medications can be administered per CMC EMS SOP’s?
Versed and Valium
What is the dosing parameters and route of administration of these medications?
Versed 2mg IN every 2 minutes, titrate to desired effect to a max dose of
10mg
Valium 5mg IVP over 2 minutes, repeat as needed to max dose of 10mg.
Valium 10mg IM
78
Case Scenario #3
You are toned out for a patient who according to bystanders “passed out”. When
you arrive you note a blue gel on the patient.
What does this indicate?
Patient is wearing a Life Vest
Your patient continues unconscious. What is your next step to assist the patient?
If patient is safe to touch, take off life vest by removing battery first. Wipe
off blue gel from patient and apply EMS pads.
CPR and ACLS medications as needed.
79
Case Scenario #4
You arrive on scene for a morbidly obese patient complaining of difficulty
breathing.
How would your airway assessment change for this patient?
Breath sounds will be difficult to hear through extra adipose tissue
Excess tissue around cheeks, lower jaw and thorax decrease airway patency
Ventilation is more difficult
Intubation will be very difficult or impossible due to patient anatomy
80
Case Scenario #5
You are called to the scene for a patient with autism. When dealing with an
autistic patient, what should EMS consider?
Allow for delayed response and avoid touching
Evaluate thoroughly for pain
Explain all actions ahead of time
Difficulty adapting to change
Constant patience and reassurance
Patient may attempt to flee with sensory overload
Decrease as much secondary noise as safely possible
81
Bibliography
•
Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th
edition. Brady. 2013.
•
Mistovich, J., Karren, K. Prehospital Emergency Care. 9th Edition. Brady. 2010.
•
Page, B. Slap the Cap-The Role of Capnography in EMS. 2012.
•
Region X SOP’s; IDPH Approved April 10, 2014.
•
www.hearthope.com
•
www.thoratec.com
•
CMC EMS System CE Module August 2015
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