wfps spring 2014 medical coned field session
TRANSCRIPT
Winnipeg Fire Paramedic
ServiceSpring 2014 Medical Continuing Education
Field Session
Objectives
Provide opportunity for questions
Demonstrate, practice with new
equipment
◦ Zoll X Series
◦ Nexiva and Clear Link
Case-based review of:
◦ Cardiac Emergencies
◦ Bleeding and Shock
New Equipment
Nexiva IV Catheter
New Equipment
CLearLink Solution Set
Nexiva IV Catheter
Septum
Stabilization
platform
Clamp
Q Syte Luer PortsExtension tubing
BD Q-Syte Split Septum
Smooth surface is
easily cleaned prior to
access
No crevices or
gaps around the
surface to harbor
bacteria
Clear housing
allows visual
assessment of
fluid path
Simple fluid path
design reduces
places for microbes to
grow
Simple Luer Lock System – eliminates multiple pieces
Posiflush
White cap
Flushing/Admin: Use Direct
Approach
ClearLink Solution Set
Luer ports – residual 0.03cc of air
Flush line – age considerations
Disinfect site prior to access
No need to “pinch line” due to back
check valve
Flush with 1ml of saline after
medication administration
Preparing Solution Set
6 month – Adult: remove air from
back check valve and Y luer ports by
inverting and tapping to flush out
bubbles
0 – 6 month: remove air from back
check valve by inverting and tapping
to flush out bubbles. Disinfect each (3)
Y luer port and withdraw air using a 10
cc syringe until saline enters syringe.
Preparing Solution Set
Back Check Valve
“Y”Luer Port
Luer Port
Direct Luer Access
Push and twist
Questions?
Case 1
04:30 call for a 58 year old female, unresponsive, but breathing
Patient’s husband called 911, wife had complained of chest discomfort/nausea then collapsed on way to bathroom
On arrival: you find the patient lying on the floor, now responding
Assessment Approach
What would you like to know?
What are your assessment priorities?
What are some differential diagnoses?
Initial Findings Vital Signs
AVPU: patient
responds to loud
voice/painful
stimulation
A: airway is patent
B: mildly
tachypnea
C: Weak, slow
radial pulses
No evidence of
trauma
Palpated pulse: 38
Spo2: not reading
RR: 26
BP: 106/68
Temp: 36.8
Further History
HPI:◦ Woke to chest
pain/nausea
◦ Collapsed on way to bathroom
◦ Assisted onto floor by husband
◦ Regained consciousness once supine, but now confused
PMHx:◦ HTN
◦ Thyroid
◦ Arthritis
◦ Positive family cardiac history
◦ Hyperlipidemia: diet controlled
Meds:◦ Metoprolol
◦ Levothroid
◦ Arthrotec
What else?
What is the rhythm?
Detailed Exam
CNS: Alert to pain/strong voice,
improves when supine, confused to
events
CVS: C/O non-specific chest
discomfort, ECG Third Degree block,
weak peripheral pulses, skin pale,
cool, diaphoretic
RESP: A/E clear=bilat, difficulty
obtaining sats
GI/GU: C/O nausea prior to collapse
MS/S: No evidence of trauma
Treatment
ABC’s
Oxygen
Establish IV
Nitrates?
◦ Nitro patch? When do you administer?
12 Lead?
STEMI?
Transport
Slightly Different Situation
What if this patient’s BP was 88/60? How would this change your treatment?
Nitrates? 12 lead/ look for STEMI? Atropine 0.5 - 1.0 mg IV◦ Responsive? Repeat q 3 to max of 0.04
mg/kg
Not responsive to Atropine? Establish TCP◦ Fentanyl?
◦ Midazolam?
Transport◦ Destination?
12 Lead Contest
Ten 12-Lead ECG’s for your
consideration
Equal number of positive for STEMI
and negative for STEMI
All are actual 12 Leads transmitted by
WFPS
Are you up for it?
Example 1
Example 1
Example 2
Example 2
ZOLL says positive for STEMI?!
Example 3
Example 3
Example 4
Example 4
Example 5
Example 5
Example 6
Example 6
Example 7
Example 7
Example 8
Example 8
Example 9
Example 9
Example 10
Example 10
Need a Break?
Case 2 21:30 call for a 22
year old male, thrown? or jumped? from a third floor window at the McLaren Hotel to sidewalk
Police arrive on scene, report conscious male, requesting “rush”
On arrival, bystanders report approximately 5 minute period of unconsciousness
Prehospital Trauma Life
Support Recall our PHTLS approach to trauma? “Find it, manage it, move on” Search for life threatening injuries and
take immediate action: treat as you go◦ If unable to manage, transport immediately
Limited interventions on scene, do this enroute◦ Recognizing that time taken with
interventions increases time to blood, surgery, CT, etc.
Consider if interventions on scene actually harm the critical patient by increasing time to definitive care
PHTLS Algorithm
PHTLS Algorithm
Other Key PHTLS Concepts
Limited scene intervention:
◦ Control bleeds, correct life-threatening
airway/breathing/circulation concerns
◦ Assist ventilations as required
Other interventions (eg. IV and fluid
resuscitation) to occur enroute
Limited scene time/ expedited
transportation to appropriate facility
Ideally; Trauma center
Other Key PHTLS Concepts
For a critical patient:
◦ Vitals on scene?
◦ Detailed history on scene?
◦ Detailed physical exam on scene?
Back to the Patient 21:30 call for a 22
year old male, thrown? or jumped? from a third floor window at the McLaren Hotel to sidewalk
Police arrive on scene, report conscious male, requesting “rush”
On arrival, bystanders report approximately 5 minute period of unconsciousness
Assessment Approach
What would you like to know?
What are your assessment priorities?
What are some expected injuries
given the kinematics of the fall?
Scene Assessment
WPS has arrived and secured scene
Scene is safe us and everyone else
Patient is in back lane and traffic has
been blocked from entering
Appears to be only one patient
EMS unit and Fire unit arrive together
◦ No need for further resources
◦ Everyone has taken standard precautions
Walking Up
What details will you look for?
General appearance?
What Next?
AIRWAY: small amount of blood in
mouth = gurgling
Cleared with suction, now patent
Now What?
BREATHING:
◦ Expose
◦ Palpate
◦ Auscultate
Treatment?
◦ NRB sufficient for now
◦ Consideration to assisting respirations/
have BVM ready
Next?
CIRCULATION:
◦ HEMORRHAGE CONTROL:
Look for external hemorrhage
Manage these bleeds
Direct pressure
◦ PERFUSION:
Assess pulse (presence, quality, rate)
Assess skin (color, temp, moisture)
Hmm…
What do you think about your findings
so far?
On to “D”
DISABILITY:
◦ Assess GCS
◦ Assess pupils
Glasgow Coma Scale
And finally, “E”EXPOSE/ENVIRONMENT
Internal Hemorrhage
If suspected, quickly expose the
abdomen and pelvis
Palpate abdomen and pelvis
There it is! When you palpate the pelvis the patient
groans loudly and it does not feel stable
When you expose you note that the
patient’s scrotum/inner thigh area is turning
purple
Later at hospital, staff sees this:
Time to go?
Set of vitals first?
Start one IV on scene?
How do we package the patient?
Immobilization? Should we immobilize this patient?
Don’t forget the blanket!
Transport
Enroute
Reassessment Vital Signs
AVPU: patient responds to strong painful stimulation
A: airway is patent
B: ^ WOB
C: Barely palpable radial pulses
◦ Skin cool, pale, clammy
D: Pupils 4mm = sluggish
◦ GCS: E-2, V-2, M-4
Pulse: 130
Spo2: not reading
RR: 28
BP: 78/40
Temp: 36.8
Blood sugar: 5.6 mmol/l
PHTLS
Easy as:
Questions?
Thanks for your participation!