Simcoe Paramedic Services CME 2010

1. Simcoe Paramedic Services CME 2010

2. Agenda • Didactic: • STEMI update • TOR • King LT • Anaphylaxis • Skills • Neonatal Resuscitation • Cardiac arrest & KING LT • Breath sounds • IM injection • IV start, fluid and dextrose administration • Scenarios • KAT

3. General Housekeeping • Did your name, address, telephone, cell phone or email change since the last CME? • If so please fill out a medic info sheet! THANK YOU

4. Auditing Housekeeping • Please ensure the use of • 010 Vital signs code. • Document Vital signs pre and post each medication administration on the ACR, not as a group at the bottom of the ACR • Do not use a procedure code (i.e. 615 NTG) when you are ruling out NTG administration. Use 030 ALS assessment

5. What do I attach to the ACR? From the LP15 printouts: • Vital sign log • ECG with O2Sat waveform (Plethysmograph) • All 12 Lead ECG’s with patients name recorded on each ECG.

6. STEMI UPDATEDr. Paul HoogeveenAnd Dr. Warren Cantor

7. Simcoe STEMI Bypass Project • Times

8. Simcoe STEMI Bypass Project • 50 patients • 6 bypassed without meeting criteria • 1 paced • 1 Aflutter with ST elevation • 1 BH MD bypass • 3 CP/symptom onset time criteria

9. Simcoe STEMI Bypass Project • Protocol < 60 minutes from patient contact to Southlake • Strict protocol regarding patient hemodynamic stability • Median transport time = 57 minutes • No adverse events

10. Simcoe STEMI Bypass Project • Summary • Meeting timeframe goals • Southlake/SOCPC Steering Committee monitoring each bypass and modifying protocol to optimize system • Patient safety maintained

11. TIME = Cardiac Muscle

12. Likely to be older (74 v 67) Women (49% v 38%) Diabetic (33% v 25%) Prior heart failure (26% v 12%) Longer delay to assessment (8% v 5%) Less likely to be diagnosed (22% v 50%) Less likely to receive treatment (25% v 74%) Most likely to die (23% v 9%) Patient Presentation 33% of patients with confirmed MI present with S & S other than chest discomfort. This group compared with those that present with chest discomfort are:

13. Pre-Hospital 12 Lead • Perform a history and physical exam • Patients ≥40 kg with signs and symptoms of cardiac ischemia you must acquire a 12 lead ECG • LP15 software will interpret findings • STEMI positive ECG *** Meets ST Elevation MI Criteria**** • STEMI negative ECG All other statements

14. 12 Lead ECG acquisition • Must be performed on all patients presenting with signs and symptoms of cardiac ischemia • Must input age and sex

15. 12 Lead ECG acquisition • 3 ECGs will be done on these patients: • First on scene as early as possible • Second prior to departure • Third upon arrival at medical facility

16. STEMI bypass (page 48) • If a STEMI positive ECG is identified and the patient meets all the criteria, and you can transport the patient within 60 minutes from STEMI identification contact SRHC

17. GRAB A PEN!!!(page 48) • STEMI Bypass inclusion criteria: Maximum time from onset of symptoms is 12 hours. • If you have a patient who has symptoms for >12 hours and has a ******Meets ST Elevation MI criteria****** you may patch to the BHP for further direction.

18. Procedure at Southlake PCI lab • How do I communicate with SRHC that I have a STEMI patient when leaving the scene? • 1-905-895-4521 ext 7777 • “This is a Simcoe County Paramedic, Unit 3---, we are transporting a Code STEMI patient, our ETA is ---, patient’s name, age, gender.” • THIS IS NOT A FULL PATCH!!!

19. TOR When to call the BHP for termination of resuscitation?

20. Age > 18 years old No ALS procedures Cardiac in nature 3 No shocks on scene Witnessed by EMS or Fire? Any shocks delivered? Was there a ROSC? YES or uncertain = continue resuscitation & transport NO = continue resuscitation and PATCH to BHP for medical TOR & continue transport. Medical TOR (page 42)

21. Trauma TOR (page 23 & 24) Trauma TOR • Age > 16 years old • Blunt trauma = Big pads • Shock delivered, transport • No shock, No pulse, HR>0, transport • No shock, No pulse, No HR, patch for trauma TOR • Penetrating trauma = Petite pads (Electrodes) • HR >0, ED <20 minutes, transport • HR >0, ED >20 minutes, patch for trauma TOR • HR 0, patch for trauma TOR • Trauma patients that have received a TOR after a patch are to be left on the scene.

22. King LT Click on video to start

23. KING LT Size 3,4,5 Inflation volume Esophageal Blind insertion 2 cuffs Distal cuff inflates in the esophagus Proximal cuff inflates at the base of the tongue LMA Size Inflation volume Supraglottic Visualized insertion Single cuff King LT versus LMA

24. Neonatal Resuscitation

25. NRP(page 32) • Prepare equipment • Team approach • 30 second blocks

26. What does meconium look like?

27. ANAPHYLAXIS REVIEW Continuing Education

28. Outline • Definition • Incidence • Pathophysiology • Signs and Symptoms • Diagnosis • Indication for Epinephrine SQ/IM • Case Presentation

29. Definition of Anaphylaxis • A systemic reaction to a protein (antigen) • Caused by the release of immunoglobulin E (IgE) • IgE acts on mast cells and basophils • Mast cells and basophils release chemical mediators; including histamine • Histamine and other inflammatory agents act on smooth muscle, connective tissue and mucous glands

30. Picturehttp://www.world-drugs.net/generic_cetirizine_clip_image002.jpgPicturehttp://www.world-drugs.net/generic_cetirizine_clip_image002.jpg

31. Incidence • Difficult to get true numbers • Many reactions are mild and not reported or misdiagnosed • Up to 15% of population may be at risk

32. Pathophysiology • Anaphylactic and Anaphylactoid reactions occur due to the systemic release of chemical mediators from mast cells and basophils • Histamine is the primary mediator involved in urticaria, bronchospasm and anaphylactic shock

33. Pathophysiology • Histamine binds to H1 and H2 receptors • Binding of histamine to H1 and H2 receptors mediates pruritis, rhinorrhea, tachycardia, bronchospasm, hypotension, flushing and headache

34. Signs and Symptoms Skin: • Itching, Urticaria • Angioedema, flushing Respiratory: • Hoarseness, stridor • Dyspnea, wheezing, rhinitis GI: • Nausea, vomiting • Cramping, diarrhea

35. Pictures: http://healthsymptomspictures.com/wp-content/uploads/2009/11/anaphylaxis.jpg

36. Signs and Symptoms Cardiovascular: • Dizziness,Chest Pain (uncommon) • Tachycardia, hypotension Neurologic: • Headache, • decreased LOA (due to hypotension +/-hypoxia), • seizures-uncommon

37. Signs and Symptoms • Skin findings are the most common BUT up to 20% of patients do not have hives or other skin symptoms • Respiratory symptoms are the second most common • deaths result from severe bronchospasm and airway and laryngeal edema

38. Diagnosis Diagnosis is made clinically: • History of exposure to possible allergen followed by development of symptoms consistent with anaphylaxis • Development of urticaria, laryngeal edema, bronchospasm and/or hypotension with other signs associated with anaphylaxis • Rebound reactions can occur up to 24 hours later

39. Treatment ? • First line is Epinephrine SQ/IM • Other treatments: antihistamines, corticosteroids, bronchodilators, IV fluids without administration of epinephrine fail to prevent or relieve severe anaphylaxis • Epinephrine in the setting of anaphylaxis has greater benefit than risk

40. What are the Indications for Epi SQ/IM • Confirmed or suspected exposure to a probable allergen • Signs and symptoms of a severe anaphylactic reaction • Involvement of more than one body system • E.g.: Urticaria and nausea • E.g.: shortness of breath with wheezing and facial edema • OR any airway symptoms

41. Case Presentation • 8 year old female began to have shortness of breath with wheezing and tightness in her throat while running a race at school • EMS is called 20 minutes later because the patient’s symptoms have not subsided and the patient now has a hoarse voice • Has had a similar reaction in the past but there was no specific allergen found • Pulse: 132, Resp: 24, BP: 80/62 Diagnosis? Treatment?

42. QUESTIONS

43. Jeopardy