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Altered Mental Status
Medication Review
Lung Sounds
MAD Device
ECRN Module I
2010 CE
Condell EMS System
Prepared by Sharon Hopkins, RN, BSN, EMT-P
Objectives
Upon successful completion of this module, the
ECRN will be able to:
 Describe elements of normal mental status.
 Describe components of the neurological
examination.
 List the three components of the Glasgow
coma scale.
 Calculate the GCS.
 List common causes of an altered mental
status.
Objectives cont’d






Review Cincinnati Stoke Scale
Describe the FAST concept
Review Region X SOP Altered Mental Status
Explain the differences between the adult and
the pediatric airway.
Describe the assessment of the airway and
respiratory system.
Describe the various lung sounds auscultated
during assessment.
Objectives cont’d


Discuss the methods for measuring oxygen
and carbon dioxide in the blood in the
prehospital setting.
Identify pre-hospital indications,
contraindications, dosing, side effects, and
special considerations of Dextrose,
Glucagon, Narcan, Albuterol, Epinephrine
1:1000, Benadryl, Lasix, and Morphine.
Objectives cont’d



Describe the indications, contraindications,
dosing, side effects, and special
considerations for administering Narcan via
the MAD tool.
Describe the MAD tool and the procedure for
using the MAD tool.
Describe the indications, contraindications,
complications, and the process for performing
a cricothyrotomy in the field.
Normal Mental Status
Consciousness
 Person is fully responsive to stimuli and
demonstrates awareness of the
environment
 Altered level of consciousness
 Some form of dysfunction or interruption
in the central nervous system

Normal Mental Status
 Patient
is awake
 Patient is alert – aware of surroundings
 Patient is oriented to person, place, & time
 Patient is cooperative
 Patient carries on normal conversation
 Patient able to follow/obey commands
 Gait is even and steady
Altered Level of
Consciousness
Hallmark sign of
central nervous
system injury or
illness
Did You Know?
 When
perfusion is declining, the first
indicator is a changing level of
consciousness
 The
last indicator is a falling blood pressure
Assessing Mental Status - AVPU
A–
awake
 V – responds to verbal stimuli
 P – responds to painful stimuli
 U- unresponsive
A – “Awake”
 Patient
is awake, alert and aware of
surroundings
 OR
 Patient may be awake but confused
 Report what the patient is oriented to
• “Oriented to person but not place or
time”
 Key
is watching for a change in level of
consciousness from the baseline taken
V – Verbal Response
 This
would need to be evaluated prior to
touching the “unconscious” patient
 Problem: If trauma is involved, need to
manually control the C-spine before
causing the patient any movement of
the c-spine
 If possible, call the patient’s name to
check for response to verbal stimuli
prior to making physical contact
P – Painful Response

Does not necessarily mean you have to
perform a painful task to check for response




Start with simple tactile contact – touch
Add deeper stimulation if needed
• Sternal rub
• Pinch of thumb web space
• Trapezius muscle squeeze (near neck)
Do not cause so much trauma as to leave
marks/bruises
Observe for some kind of response with muscles
Patient Response
 Patient



response can include:
Opening of eyelids even briefly
Fluttering of eyelids
Wrinkling of brows
 Most
important is looking for changes in
the patient’s response from one
evaluation/assessment to the next
U - Unresponsive
 The


patient has NO response at all
No moaning
No muscle twitch at all
• No eyelid flutter
• No wrinkling of the eyebrow

Muscles are flaccid with absolutely no
response regardless of stimuli
Neurological Exam In the Field
AVPU – what is level of consciousness?
 Pupillary response
 Movement of distal extremities



Sensation of distal extremities


Wiggling fingers and toes
Ability to feel contact with fingers and toes
GCS

<10 or deteriorating mental status patient is
considered critical and categorized as Category I
trauma
Glasgow Coma Scale - GCS

The best score possible is given
 More important is watching the trend than
relying on any one score
 Objective tool


All using the tool on the same patient should get
the same score
Evaluate



Best eye opening
Best verbal response
Best motor response
GCS – Eye Opening

4 – Spontaneous; patient’s eyes are open


3 – Eyes open or motion is made to verbal
stimuli


Start with soft voice, may have to yell at patient to
open eyes
2 – Eyes open with tactile or painful stimuli


Does not have to be focusing
Start with gentle touch; may need to add more
intense stimuli
1 – No eye opening; no muscle motion at all
GCS – Verbal Response
– Oriented to person, place, and time
 4 – Pleasantly confused
 3 – Inappropriate words
5

2

1
You can understand the word(s) spoken
but they are not within context
– Incomprehensible words – sounds
No intelligible word understood; moans and
groans; makes noises
– Silent; no noise is made at all
GCS – Motor Response
– Obeys commands
 5 – Localizes pain / purposeful movement
6

4

Can push you away or grab at the noxious
stimuli (IV, collar, bandaging, your hands)
– Withdrawal
No longer localizing, just withdraws/pulls
away to get away from annoying/painful
stimuli (IV, collar, bandaging, your hands)
Motor cont’d
3

2

1
– Flexion to pain
Arms flex/bend slowly toward center of chest
when any stimuli applied
– Extension to pain
Arms slowly extend and curl inward and legs
straighten when any stimuli applied
– No movement at all
GCS Results
range 3 – 15
 Minor head injury – 13 – 15
 Moderate head injury – 9 – 12
 Severe head injury (coma) - <8
 Score


Significant mortality risk
Consider intubation or other means to secure
the airway
GCS Practice






Read the following case scenarios
Determine the best eye opening, verbal
response, motor response
When the response is asymmetrical, award
the highest points possible
Don’t guess or assume what you think they
really can do
Award points for what is performed
Be objective
 Note: Answers follow the practice slide
GCS Case #1
 Patient
lying in the bed (no trauma), eyes
are closed
 You need to yell the patient’s name and
then the eyelids flicker
 They are mumbling
 They are grabbing at your hands and
pushing you away. They have pulled out
the IV.
GCS Case #1 Score
 Eye

opening – 3
Responded to loud voice
 Verbal

Mumbling is incomprehensible words/sounds
 Motor

response – 2
response – 5
Patient can recognize (localize) what feels
obnoxious and what he wants to stop so they
are grabbing at you and pulling at equipment
 Total
GCS - 10
GCS Case #2
 Patient
is lying in the street watching you
approach
 They mumble as you talk to them
 They are grabbing at your hands and
pushing you away
GCS Case #2 Score
 Eye

opening – 4
Spontaneous; doesn’t necessarily indicate
focusing
 Verbal

Mumbling, moaning, groaning
 Motor

response – 2
response – 5
Purposeful movement by grabbing at what
the patient perceives as noxious stimuli
 Total
GCS - 11
GCS Case #3
 Patient
watches your approach and
acknowledges your presence
 Patient answers most questions and thinks
you are their relative come to visit
 Patient able to move left arm to command
but not able to move right arm (new onset
– possible stroke)
GCS Case #3 Score
 Eye

opening – 4
Spontaneous
 Verbal

Pleasantly confused
 Motor

response – 4
response – 6
Highest possible score based on the arm that
can and does move
 Total
GCS - 14
GCS Case #4
 Child’s
eyelids flicker when deformed
extremity is manipulated
 Child moans out when painful areas are
manipulated
 Child pulls away when touched and tries to
turn away from EMS
GCS Case #4 Score
Eye opening – 2
 Response to painful stimuli
 Verbal response – 2
 Moans and groans are incomprehensible
words / sounds
 Motor response – 4
 Withdrawing from what is sensed as painful
stimuli
 Flexion would be slow flexing of arms toward
center of chest – this patient’s response is not
flexion
 Total GCS – 8 (Protect airway; consider intubation)

GCS Case #5
 Patient’s
eyes remain closed; no eyelid
movement at all
 There are no sounds heard from the
patient
 The patient straightens their arms, twists
their wrists, arches their back, and
straightens their legs when stimulated
GCS Case #5 Score
opening – 1 (no response)
 Verbal response – 1 (no response)
 Motor response – 2
 Eye


Abnormal extension
The worse level of response prior to no
response at all
 Total


GCS – 4
Patient is critical; Category I
Patient usually needs some airway
intervention
Common Causes of Altered Mental
Status









A – acidosis, alcohol
E – Epilepsy
I – Infection (brain, sepsis)
O – Overdose
U – Uremia (kidney failure)
T – Trauma, tumor, toxins
I – Insulin – hypo or hyperglycemia
P – Psychosis, poison
S – Stroke, seizure
Initial Patient Assessment
 Airway


Open or obstructed
Maneuvers needed to open
• Head tilt / chin lift
• With trauma, modified jaw thrust
 Breathing


Quality
Quantity (eyeball assessment at this time)
Initial Assessment cont’d
 Circulation


Quality
Quantity (don’t count; get estimate of
range)
 Disability


AVPU
GCS
 Expose

– need to obtain baselines
to examine
Can’t evaluate or fix what you can’t see
Assessment Tools
 AVPU




Alert (interpreted as an awake patient)
Responds to verbal stimuli
Responds to painful stimuli
Unresponsive
Assessment Tools
 GCS



Best eye opening response
Best verbal response
Best motor response
 Scores
range from the lowest of 3 to
highest of 15
 Obtain and document GCS on all patient
calls
Cincinnati Stroke Scale
 Obtain
for suspicion of TIA or stroke
 Evaluate for facial droop
 Check the patient’s symmetry during a
broad, big smile (teeth showing)
 Evaluate for arm drift
 Check for weakness in holding arms
outstretched, palms up, for 10 seconds
 Evaluate for clear speech
 Have patient repeat words listening for
clear speech patterns
Airway Protection and the Stroke
Patient
 Crucial
- high mortality rate for aspiration
 Is airway patent and can patient protect
their own airway?

Check if patient is able to handle & swallow
own saliva
• Detailed/involved swallow study done in-hospital

Patient speaks in clear unobstructed voice
 Interventions


to consider
Have suction on and ready
Ability to quickly turn patient onto their side
FAST - Public
Educational
Tool
 Tool
developed by
organizations
for public
recognition of
stroke and to
encourage
FAST action
Region X SOP –
Altered Mental Status
 Consider

etiology
If cause of problem can be identified, then
interventions can be focused
• Diabetes – check blood sugar
• Drug overdose – what are the
environmental clues
• Poisoning – environmental evidence
around
• Alcohol related – environmental
evidence; use your nose
SOP – Altered Mental Status

Maintain airway


Patency extremely important
Evaluate rate and quality

If respirations inadequate, ventilate
• 1 breath every 5-6 seconds all patients –
infancy to elderly

Intubate as necessary
 Use C-spine precautions as indicated


If any doubt, err on side of extra precautions
Provide Routine Medical Care

IV – O2 - monitor
SOP – Altered Mental Status
 Obtain

blood glucose level
If <60 – treat
• Adult - Dextrose 50% 50 ml IVP
• Child 1 – 15 – Dextrose 25% 2 ml/kg
• Infant <1 – Dextrose 12.5% 4 ml/kg
 Dilute 1:1 ratio D 25% with normal
saline
 Equal amounts of product make 1:1
dilution (Dextrose and normal saline)
Treating Altered Mental Status


In absence of IV access
• Adult – Glucagon 1 unit (1 ml) IM
• Pediatrics < 15 – Glucagon 0.1 mg/kg IM
 Max dose of 1 mg
Practice math: 44 pound child with no IV access
• How many kg?
 44#  2.2 = 20 kg
• 20 kg x 0.1mg/kg = 2 mg
• How much Glucagon do you give?
 Max of 1 mg (max drugs at adult dose)
Altered Mental Status cont’d

If patient not alert, respirations decreased, or
narcotic overdose suspected:
 Narcan 2mg IN/IVP/IO
• Repeat every 5 minutes as needed until
desired effect



Quality of respirations have improved
Don’t need patient to be 15 on GCS
Don’t need patient awake necessarily
• Maximum total dose 10 mg
 Transport
Altered Mental Status cont’d
 Note:



Attempt to identify substances involved
If not a safety hazard, obtain and transport
substance container with the patient
Consider use of restraints prior to
administration of Narcan
• Patient may become violent when level
of consciousness improves
 Adult Airway
 Note
Pediatric airway
funnel shaping of pediatric airway
Notice Difference in Tongue Size


Adult airway
tongue
Pediatric airway
Pediatric airway Differences

Jaw smaller
 Teeth softer and more fragile
 Tongue relatively larger
 Potential to produce more obstruction
 Epilgottis floppier and rounder
 Recommend straight Miller blade over curved Macintosh
for intubation
 Larynx more superior & anterior
 Higher and more forward
 Funnel shaped due to underdeveloped cricoid cartilage
• Under age 10 cricoid cartilage narrowest part of airway
 Ribs and cartilage softer and more pliable
 Children rely on diaphragm muscle for breathing
Airway Assessment
 Inspection

Begin as you are approaching the patient
 Auscultation

Listen for audible sounds, then use
stethoscope
 Palpation

Can gather a lot of information through the
art of touch
Assessment of Airway

Initial assessment
 ABC’s
• Airway open?
 Fully open with adequate air exchange?
 Partially or fully obstructed with poor air
exchange?
• Are they breathing?
 Look for chest rise and fall
 Listen for air movement
 Feel for air movement
• Do they have a pulse?
Airway Assessment cont’d
 Inspection



Evaluate adequacy of breathing
Note any signs of trauma
Assess skin color
• Paleness and diaphoresis due to sympathetic
stimulation in early respiratory compromise
• Cyanosis if deoxygenated (LATE SIGN!!!)

Patient positioning
• Tripod – leaning forward (CHF? Asthma?)
• Orthopnea – can’t lay down (CHF? Asthma?)
Inspection cont’d

Observe for dyspnea
• May cause or be caused by hypoxia
• Prolonged dyspnea can lead to anoxia
(absence of oxygen)
• Is dyspnea a new onset or perhaps chronic
in the patient with long standing COPD
Abnormal Respiratory Patterns
 Kussmaul’s


Deep, slow or rapid, gasping breathing
Commonly found in diabetic ketoacidosis in
attempt to blow off excess CO2 (acid)
 Cheyne


–Stokes
Progressively deeper, faster breathing
alternating with gradually shallow and slower
breathing
Indicates brainstem injury
Respiratory Patterns cont’d

Biot’s



Central neurogenic hyperventilation



Irregular pattern of rate and depth with sudden,
periodic episodes of apnea
Indicates increased intracranial pressure
Deep, rapid respirations
Indicates increased intracranial pressure
Agonal


Shallow, slow, or infrequent breathing
Indicates brain anoxia, impending death
Respiratory Assessment cont’d
 Auscultation



Listen 1st audibly for any abnormal sounds
Have patient cough to clear loose secretions
Then listen with stethoscope
• Right and left apex (under clavicles)
• Right and left bases (8th – 9th intercostal
space, midclavicular)
• Right and left lower thoracic back or right
and left midaxillary line (lateral chest wall)
Auscultation cont’d
 Posterior
aspect preferable to anterior surface
 Less tissue mass
 Lungs closer to the surface
 Less interference with heart sounds
 Anterior and lateral sections of the chest are
more accessible especially in supine patients
 Evaluate for symmetrical equality
 Keep stethoscope in place long enough to
hear end of exhalation
 Many abnormal sounds heard first at end of
exhalation
Abnormal Lung Sounds
 Snoring


Partial obstruction of upper airway, usually
from tongue
Patient needs airway repositioned
 Gurgling

Accumulation of fluids (blood, vomitus,
other secretions) in upper airway
 Stridor

Harsh, high-pitched sound heard on
inhalation; usually indicates laryngeal
edema or constriction
Lung Sounds cont’d
 Wheezing


Musical, squeaking, or whistling sound
heard in inspiration and/or exhalation
Indicates bronchiolar constriction
• Asthma, COPD
 Quiet


Diminished or absent breath sounds
ominous
Indicates serious problem with airway,
breathing, or both
Lung Sounds cont’d

Crackles (rales)
 Fine, bubbling sound heard on inspiration,
sounds like velcro ripping
 Indicates fluid in smaller airways
• CHF
• Pneumonia
 Gas exchange may be compromised
 Rhonchi
 Course, rattling noise heard on inspiration
 Associated with inflammation, mucus, or fluid in
bronchioles
 Gas exchange may be compromised
• Chronic bronchitis
Airway Assessment

Palpation
 Often forgotten assessment tool
 Palpate chest wall for
• Tenderness
• Symmetry
• Abnormal motion
• Crepitus (bone crunching)
• Subcutaneous emphysema
 Air leakage into tissue
Pulse Oximetry
 Measures
hemoglobin oxygen
saturation in peripheral tissue
 Non-invasive means to measure
effectiveness of oxygenation and
ventilation
 Continually reflects changes
 May detect changes faster than
assessment of vital signs
Pulse Oximetry
 Place
probe over a peripheral capillary bed
 Fingertip, toe, earlobe
 2 sensors take measurements of light
reaching them from 2 light emitting diodes
 Oximeter calculates ratio of light received
• Influenced by amount of oxygenated
versus deoxygenated hemoglobin
 SpO2 determined
Suggested SpO2 Results
– 99% - normal
 91 -94% - mild hypoxia
 95


Perform additional evaluation
Administer supplemental oxygen
 86


– 91% - moderate hypoxia
Perform additional evaluation
Administer 100% supplemental oxygen
 <85%

- severe hypoxia
Immediate intervention required
SpO2 Error Results

Current equipment more accurate; less error
readings
 False readings possible






Carbon monoxide exposure – false high
High-intensity lighting near sensors
Hemoglobin abnormalities
Absent peripheral pulses
Hypovolemia; severe anemia
• SpO2 may be normal but the amount of
hemoglobin available is low
Coordinate readings with patient assessment
Capnography
 Graphic
recording or display of
measurement of expired CO2 over time
 End-tidal CO2 (ETCO2) – measurement of
CO2 concentration at end of expiration
 Provides information
 Systemic metabolism (production of CO2)
 Circulation
 Ventilation
How Does CO2 Circulate?
 CO2
is normal end product of
metabolism
 Transported by venous system to right
side of heart
 Pumped from right ventricle 
pulmonary artery  lungs and
pulmonary capillaries
 Diffuses into alveoli
 Removed from body via exhalation
Poor Perfusion States
 Shock,
cardiac arrest, pulmonary
embolism, bronchospasm, incomplete
airway obstruction (ie: mucous
plugging)
 Perfusion decreased
 ETCO2 will reflect pulmonary blood
flow and cardiac output
 Will not reflect ventilation in poor
perfusion states
End Tidal CO2 Detector
 Contains
pH sensitive chemically
impregnated paper to estimate ETCO2
level
 Color change is reversible
 Will reflect changes breath to breath
 Paper will be unreliable if
contaminated with acidic
drugs or gastric contents
 Tool placed near elbow on
BVM
Interpreting the ETCO2
– indicates measured CO2 being
exhaled
 Yellow

Evaluate after 6 breaths
 Tan

– low levels of CO2 measured
Misplaced tube or poor carbon dioxide
production
• Evaluate tube positioning
• Evaluate patient perfusion
 Blue

or purple – no CO2 being measured
Suspect unsuccessful intubation
ETCO2
 Applications


Verify placement of endotracheal tube
Assess effectiveness of CPR
• CO2 levels fall abruptly at onset of
cardiac arrest
• CO2 levels begin to rise with effective
CPR
Medication Review
(Information based on Region X EMS usage)
Indication
Contraindication
Dosing
Side effects
Special considerations
Dextrose

Carbohydrate used to raise the sugar level
 No contraindication in suspected hypoglycemia
 Administered when the blood sugar level is less
than 60
 Dose based on age
 Adult 16 and over – 50% 50 ml slow IVP
 1 – 15 – D 25% - 2 ml / kg slow IVP
 <1 – D 12.5% - 4 ml / kg slow IVP
• Mix 1:1 dilution with D25% and normal
saline
Dextrose cont’d
 Local
vein irritation may occur
especially when small veins are used
 If glucagon was administered and then
an IV site is secured, retest the blood
sugar level

If blood glucose remains <60 and patient
condition not improved, administer
Dextrose
Glucagon
 Hormone
to stimulate breakdown of
glycogen (stored form of glucose)
 Patient may have an allergic reaction if they
have allergies to proteins
 Adult dosing – 1 mg (1 unit) IM
 Pediatric dosing up to 15 years old –
0.1 mg/kg (max dose 1 mg – 1 unit)
Glucagon cont’d
 Observe
for nausea and vomiting
 May take up to 20 minutes for Glucagon
to be effective
 Will not have any effect if there are no
stores of glycogen in the liver
 Patient requires rapid transport and
continued efforts at IV access
 Drug must be reconstituted prior to
administration
Albuterol
 Ventolin,
Proventil
 Bronchodilator with onset 5 – 15 minutes
after inhalation
 Used in asthma, to reverse bronchospasm
in COPD, and bronchospasm & laryngeal
edema of an allergic reaction
 All patients inhale 2.5 mg via nebulizer
Albuterol cont’d
 May
cause tachycardia & restlessness
 Has greater influence in the lungs than
on the heart
 Less effective if patient taking beta
blockers at home (usually for
hypertension; meds end in “alol”)

Beta blockers block bronchodilation
response
 Offer
aerosol mask if patient unable to
keep mouthpiece sealed between lips
Albuterol Kit and Masks
2.5 mg / 3 ml
Connected
to O2
source
 Watch
Available in
adult and
pediatric sizes
for
signs of
exhaustion
 May need to
be bagged
Epinephrine via Nebulizer
 In


presence of croup/epiglottits
If patient not responding to 2 doses of
Albuterol, provide alternate treatment
• Epinephrine 1:1000 1 ml mixed with
2 ml normal saline
• Mix in nebulizer
• Connect to oxygen to create a mist
• Assist patient while inhaling the mist
Nebulized Epinephrine for moderate to
severe cases
Epinephrine 1:1000

A drug that mimics the sympathetic nervous system
 Stimulation on the vessels trigger
vasoconstriction
• Will raise the blood pressure
 Stimulation in the lungs triggers bronchodilation
• Will improve air exchange
 Useful in asthma, COPD, allergic reactions with
airway involvement, and anaphylaxis
Epinephrine 1:1000 cont’d
 Use
with caution in the elderly and
those with heart disease

Can strain the heart by increasing the
workload of the heart (rate and force of
contractions)
 Adult
dosing allergic reaction with
airway involvement – 0.3 mg SQ
 Adult dosing anaphylaxis – 0.5 mg IM

Faster absorption in poor perfusion
Epinephrine 1:1000 cont’d
 Pediatric

dosing up to 15 years of age
Allergic reaction with airway involvement
• Epi 1:1000 - 0.01 mg/kg SQ
• Max single dose 0.3 ml (0.3 mg)
• May repeat every 15 minutes

Anaphylaxis
•
•
•
•
Epi 1:1000 – 0.01 mg/kg IM
Max single dose 0.3 ml (0.3 mg)
IM faster absorption in poor perfusion state
May repeat every 15 minutes
Epinephrine 1:1000 cont’d
 May





Tachyarrhythmias
Palpitations
Restlessness
Anxiety
Headache
 May

cause:
increase oxygen demand in the heart
Use cautiously in elderly and those with heart
disease
Benadryl - Diphenhydramine
 Antihistamine
to block the release of
histamine in allergic reactions
 Max effect in 1 – 3 hours
 Duration of effect 6 -12 hours

Medication must be continued over several
days or symptoms will rebound
 Useful
in allergic reactions including
anaphylaxis
Benadryl cont’d
 Avoid
use in severe, uncontrolled asthma
and COPD
 Adult dosing


Stable allergic reaction – 25 mg slow IVP or IM
Allergic reaction with airway involvement &
anaphylaxis – 50 mg slow IVP or IM
 Pediatric


dosing – 1 mg/kg IVP
Stable allergic reaction – max dose 25 mg
Allergic reaction with airway involvement or
anaphylaxis – max dose 50 mg
Benadryl cont’d
 May
cause drowsiness, headache,
confusion, wheezing, palpitations,
hypotension, nausea, vomiting, drying of
secretions
 Elderly particularly sensitive to effects of
Benadryl

Watch for hypotension and drowsiness
Lasix (furosemide)
 Diuretic
that stops reabsorption of
sodium and chloride in the kidneys
 Triggers dilation of the venous system


Could drop blood pressure
Decreases pre-load
Amount of blood returning to the heart
 Onset
of venodilation immediate
 Onset of diuretic effect within 15 – 20
minutes
Lasix (furosemide) cont’d
 Useful
in CHF and pulmonary edema
 Venodilation useful in hypertensive
crisis
 Slight risk in persons allergic to sulfa
drugs (typically antibiotics)
 Dosing is 40 mg IVP/IO
 If patient is on Lasix, they are
sensitized to it
 Use the larger dose of 80 mg IVP/IO
Lasix (furosemide) cont’d
 May
cause headache, dizziness,
hypovolemia, nausea
 Patient may experience temporary hearing
loss and ringing in the ears with repeated
doses given rapid IVP/IO over a period of
time
Morphine

Narcotic analgesic (opioid)
 Reduces anxiety
 Creates a euphoric feeling
 Depresses the central nervous system (CNS)
• Reduces pain sensation
 Dilates venous blood vessels
• Decreases blood return to the heart (pre-load)
 Useful in ACS, pulmonary edema, pain
 Potentiates versed during conscious sedation
 Helps versed to be more effective
Morphine cont’d
 Dosing



2 mg given slow IVP (over 2 minutes)
May repeat every 2-3 minutes
Maximum total dose is 10 mg
 Side




effects
Hypotension
Respiratory depression
Bradycardia
Altered level of consciousness
Morphine cont’d
 Opioids
cause pupils to constrict
 Use cautiously when other depressant
drugs have been taken

Includes alcohol
 Reversal

agent is Narcan
Adult dosing 2 mg IVP
• May repeat every 5 minutes; max total 10 mg

Pediatric dosing < 20kg – 0.1 mg/kg
IVP/IO/IM
• Max total dose is 2mg
• > 20kg – 2 mg IVP/IO/IM
Narcan

Narcotic antagonist with an onset within
2 minutes
 May cause withdrawal symptoms including
seizures
 Adult dose – 2 mg IN/IVP/IO


Repeated every 5 minutes as needed up to 10 mg
Pediatric dose up to 15 years weight based


<20 kg (44#) – 0.1 mg/kg IVP/IO/IM
>20 kg (44# - typically a 4-6 year old) –
2 mg IVP/IO/IM
Narcan cont’d
 Side
effects are rare. Watch for
hypotension, nausea, vomiting, blurred
vision, opiate withdrawal (including
seizures)
 Goal is to reverse severe respiratory
depression; NOT to have an awake &
talking patient
 Duration of Narcan may be shorter than
drug it is trying to counteract

Watch for return of symptoms
Alternate Medication Delivery MAD
 Mucosal
atomization device
 Tool to deliver medications via nasal route
 Medication atomized into tiny particles
 Nasal mucosa highly vascular
• Immediate absorption into bloodstream
• Onset of action within 3-5 minutes
• Peak onset 15-20 minutes
Using Nasal Route - MAD
 Unable
to establish IV access
 Medication administration indicated
 Nasal mucosa intact and
clear of blood and mucus
MAD
 Luer
tip can be connected to variety of sizes
of syringe
 White wedge fits firmly into nostril
 Fine mist spray covers a large surface area
 Medication adheres to nasal mucosa
versus running down the throat
 Each nostril can tolerate up to 1 ml volume

Narcan packaged 2mg/2ml – will need to deliver
1 ml in each nostril
Attaching MAD Tip to Syringe


Nasal cavity suctioned as needed to clear
blood or secretions
• Clear nasal passages enhance absorption
of medication
Medication delivered in divided doses
• Maximum of 1 ml per nares
Inserting MAD Nasal

Patient’s head controlled with
one hand
 Need to prevent movement
•
MAD gently but firmly placed
into one nostril
• Aimed upward and toward
ear on same side

Syringe briskly compressed
to deliver the drug as an
atomized mist into nares
Dispensing Mist

Must briskly compress
syringe to convert liquid
drug to a fine atomized
mist
 Mist results in broader
mucosal coverage;
better chance of
absorption into the
blood stream than
drops that can run
straight back into the
throat.
MAD
 Region
X have implemented the MAD
beginning with Narcan
 “IN” documented for route of
administration
 Will have the potential in the future to
add further medication using the MAD
Cricothyrotomy, QuickTrach
 Indications

Assisted ventilations required and all other
means have failed to secure an airway
 Contraindications


Transected trachea
Less invasive maneuver will be effective
 Note:
In ED, staff will need to assist the
MD with this device – do you know how?
Equipment


BVM
QuickTrach kit
 >77 pounds use 4 mm kit
 22 – 77 pounds use 2 mm kit
 < 22 pounds use needle cricothyrotomy
 Skin prep material
Where is your airway kit kept in the
ED?
QuickTrach Kit
Contents
 Needle
with syringe
 Cannula with wings
for strap attachment
 Extension tubing
 Velcro strap
QuickTrach cont’d

Procedure (RN to assist MD)
 Assemble equipment
 Patient supine, neck hyperextended if no trauma
 Locate cricothyroid membrane and cleanse site
• Soft spot palpated just below Adam’s apple
• Or, start at notch, run fingers up toward head
 First ridge of bone palpated is cricoid
cartilage
 Membrane is just above this bony
cartilage
Procedure cont’d







Anchor and stretch skin slightly
Puncture cricothyroid membrane at 900 angle
Aspirate syringe as needle enters trachea to confirm
placement
• Ability to freely aspirate air
Change angle of needle to 600 towards feet
Advance device until stopper is flush with skin
Remove stopper
• Stopper will be snug; avoid motion of needle
Slide plastic cannula forward until snug against skin as
you remove needle and syringe
• Advance cannula as you remove needle like starting
an IV
Procedure cont’d





Hold cannula snuggly
• Patient may reflexively cough and could
dislodge cannula
Attach flexible connecting tube to cannula
proximal end
Begin to bag/ventilate the patient immediately
• Once every 6-8 seconds for all patients
Confirm placement
• Auscultation lung sounds
• Adequate chest rise
Finish securing cannula with neck strap
Case Study #1
 Your
patient called 911 after dropping her
tea cup and being unable to move her
right side
 Conscious, cooperative, speech slurred
 VS: 175/110; P – 98; R – 18; pupils
cataract
 Initial care started (IV – O2 – monitor)
 What is your impression?
 What specific assessment should be
done?
Case Study #1 cont’d

Impression
 Acute stroke
 Additional assessment
 Cincinnati Stroke Scale
• Facial droop
• Arm drift
• Speech
 Transport decision
 Is CT scan available at receiving hospital?
Case Study #2

EMS is at a local school for a patient with asthma
 Assessment taken walking towards child
 Sitting upright
 In obvious distress
• Use of accessory muscles – neck,
intercostal
• Increased respiratory rate
• Panic on their face
 Impression
• Severe acute asthma attack
 Is assessment done after vital signs?
Case Study #2 cont’d
 Assessment




performed
Observation / visual inspection
Initial ABC’s
• To determine presence of life threats
Breath sounds auscultated
• Bilateral wheezing heard predominately on
exhalation
Obtain vital signs
• 98/62; P – 110; R – 28 and labored; SpO2 94%
Case Study #2 cont’d
 Interventions

required
IV – O2 – monitor - medication
 Question

Do you need an IV established prior to
administration of medication?
• No, albuterol nebulizer should be started as
soon as possible
• Give verbal prompts to slow breathing down, to
take deeper breaths, and to eventually take and
hold a deep breath
Case Study #3





You are caring for a traumatically injured
patient
When asking them to open their eyes, you
yelled their name and their eye opened briefly
and then closed again
They are using swear words during care
provided
They are pulling off equipment and grabbing
at your hands while you provide care
What is their GCS?
Case Study #3 cont’d
 Eye

opening
To verbal – 3 points
 Verbal

Inappropriate words – 3 points
 Motor

response
Purposeful movement – 5 points
 Total

response
GCS – 11 points
Indicates moderate head injury
Case Study #4
 You
are caring for a patient complaining
of dyspnea
 Your patient is 62 years-old
 They are sitting in the tripod position
 They are using accessory muscles and
have an increased respiratory rate
 With your stethoscope, you auscultate
crackling sounds heard in the bases
during exhalation
Case Study #4 cont’d

What are these breath sounds?


What do these breath sounds indicate?


Fluid in the smaller airways
• CHF, pulmonary edema, pneumonia
What medications may be indicated in the
field (per SOP) for CHF?





Crackles
Nitroglycerin – venodilator
Lasix – venodilator and diuretic
Morphine – venodilator, reduce anxiety
And of course, oxygen
Intervention to add is CPAP
Case Study #5
 You
received a 7 year-old patient from a
local school with an asthma attack
 Your impression is an acute asthma attack
 You begin supplemental oxygen and begin
to prepare to provide interventions
Case Study #5 cont’d

If this is an asthma attack, what signs and
symptoms do you expect?
 Sitting up leaning forward
 Dyspnea with shortness of breath
 Increased respiratory rate
 Use of accessory muscles
 Dry mucous membranes
 Possibly audible wheezing
 Bilateral wheezing heard first on exhalation
 Dry, nonproductive cough
Case Study #5 cont’d
 If
you cannot hear any breath sounds,
what does this mean?

The airway is so constricted that no air is
moving in or out – ominous
 What

does wheezing sound like?
Whistling, musical sound that can be heard
on inhalation and exhalation
• The louder the breath sounds the more
air that is exchanging
Case Study #5 cont’d

What medication is indicated?


Albuterol 2.5 mg (in 3 ml) nebulizer
How can you help maximize the effects of the
treatment?




Calmly, quietly talk the patient through breathing
Get the patient to slow down the breathing
Get the patient to take some deeper breaths
Get the patient to inhale and hold their breath
periodically to get the drug into the lungs
Case Study #6
 You
have an unresponsive male in his
twenties
 The patient responds to painful stimuli
 The respirations are 6 per minute and
shallow
 Pupils are constricted
 What is your impression?
 What interventions were necessary in
the field?
Case Study #6
 Impression
Narcotic overdose
 Interventions
 Immediately support ventilations
• Bag at a rate of once every 5-6 seconds
 Protect the airway from aspiration
 Administer Narcan 2 mg (via MAD if no IV)
• Administer a maximum of 1 ml per nares
if using MAD

Case Study #7
 A patient
is unable to be ventilated via
BVM
 What options are available?

Reposition the airway
• Consider c-spine precautions if indicated



Attempt intubation
QuickTrach if unable to intubate
Needle cricothyrotomy if unable to identify
landmarks
Case Study #7
 Landmarks


for Quicktrach
Soft space just inferior/below thyroid cartilage
(Adam’s apple)
Or
Start in notch and move finger upward
• Feel first bony prominence – cricoid
cartilage
• Palpate for soft space above the cricoid
cartilage
Bibliography





Bledsoe, B., Porter, R., Cherry, R. Paramedic
Care Principles and Practices. Prentice Hall.
2009.
Campbell, J. BTLS 5th Edition. Brady. 2004.
Region X SOP, March 2007; amended January
1, 2008.
videolaryngoscopy.com/…/AdultCobaltAirway.jpg
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