EMRG1300 Flashcards
IV Therpy MD- Indications
Actual or potential need for IV medication or fluid therapy
IV Therapy MD- Conditions
IV Cannulation:
- Age: ≥ 2 years
0.9% NaCl- Fluid Bolus:
- Age: ≥ 2 years
- SBP: Hypotension
IV Therapy MD- Contraindications
IV Cannulation:
- Suspected fracture proximal to access site
0.9% NaCl Fluid Bolus:
- Fluid Overload
IV Therapy MD- Treatment 0.9% NaCl Maintenance Infusion
Age: ≥ 2 years to < 12 years
Infusion: 15ml/hr
Age: ≥ 12 years
Infusion: 30-60 ml/hr
IV Therapy MD- Mandatory Provincial Patch Point
Patch to BHP for authorization to administer 0.9% NaCl fluid bolus to hypotension pt’s ≥ 2 to < 12 years with suspected DKA
IV Therapy MD- 0.9% NaCl Fluid Bolus
Age: ≥ 2 years to < 12 years
Infusion: 20ml/kg
Reassess every: 100ml
Max Volume: 2000ml
Age: ≥ 12 years
Infusion: 20ml/kg
Reassess every: 250ml
Max Volume: 2000ml
Paramedics can monitor an IV line for fluid replacement:
- A max flow rate of up to 2 ml/kg/hr to a max of 200ml/hr
- Thiamine, multivitamin preparations
- Drugs within his/her level of certification
- Potassium chloride for patients ≥ 18 years of age, to a max of 10mEq in a 250 ml bag
A paramedic shall request a medically responsible escort in the event a patient requires an IV for:
- Blood (or blood products) administration
- Administering potassium chloride to a patient who is < 18 years of age
- Administering medication that is outside his/her scope of practice
- Requires IV fluid infuser, pump, or central venous line
- Neonate or pediatric pt < 2 years
What should the paramedic do pre-transport? (IV Line Standard)
- Confirm physicians written order with sending facility staff
- Determine IV solution, IV flow rate, catheter gauge, catheter length, and cannulation site
- Note the condition IV site prior to patient transport
- Confirm amount of fluid remaining in bag
- Determine amount of fluid required for complete transport time and obtain more fluid if applicable
- Document all pre-transport IV information
What should the paramedic do during transport? (IV Line Standard)
- Monitor and maintain IV at the prescribed rate, this may include changing the IV bag as required
- If IV becomes dislodged or interstitial, discontinue the IV flow and remove the catheter with aseptic technique
- Confirm condition of catheter if removed
How much fluid should be remaining when you change the IV bag?
Approximately 150 mls of solution
What is PCP Assist IV?
Authorization for a PCP to cannulate a peripheral IV at the request and under the direct supervision of an ACP
- They ARE NOT authorized to administer IV therapy
What is PCP Autonomous IV?
Authorization for a PCP to independently cannulate an IV according to the MD.
- They ARE authorized to administer IV therapy
ROSC MD- Indications
Pt with ROSC after resuscitation was initiated
ROSC MD- Conditions
0.9% NaCl Fluid Bolus
- Age: ≥ 2 years
- SBP: hypotensive
- Other: Chest auscultation is clear
ROSC MD- Contraindications
Fluid Overload
ROSC MD- What do we titrate oxygenation to?
94-98%
ROSC MD- What do want to avoid with ventilations?
Hyperventilation- target ETCO2 to be between 30-40mmHg
ROSC MD- Treatment 0.9% NaCl Fluid Bolus
Infusion: 10ml/kg
Interval: Immediate
Reassess every:
100 ml for ≥ 2 years to < 12 years
250 ml for ≥ 12 years
Max Volume: 1000 ml
Conditions for Trauma TOR
Age: ≥ 16 years
No palpable pulses
No defib delivered
Rhythm asystole
No signs of life since extricated OR
signs of life since extricated and closest ED is ≥ 30 mins OR
Rhythm PEA and closest ED is ≥ 30 mins
Conditions for Medical TOR
Age: ≥ 16 years
Paramedic did not witness arrest
No ROSC 20 min of resus
No defib delivered
No reversible cause of death
What are crystalloids?
Dissolving crystals such as SALTS and SUGARS in water. Contain NO PROTEIN!!!
What is the action of crystalloids?
Remain in the intravascular space for only a short time before diffusing across capillary walls into the tissues
Examples of crystalloids?
Normal saline and lactate ringers
What are colloids?
Contain large molecules such as PROTEINS
What is the action of colloids?
Do not pass through capillary membranes as readily
Examples of colloids?
Volume expanders, plasma substitues, plasma, RBC’s, whole blood. Plasmatane, hetastarch, dextran
What is a hypotonic solution?
Lower solute in solution than the cell- causes water to go into the cell (NR, LR)
What is a hypertonic solution?
Higher solute in the solution- causes water to leave the cell (Mannitol)
What is an isotonic solution?
Equal solute inside and outside the cell
Pathophysiology of emphysema?
- Thickening of bronchial walls
- Narrowed airways
- Difficult expiration leads to air trapping = barrel chest
- High CO2 levels
Pathophysiology of Bronchitis?
- Mucosa is inflammed and swollen
- Increased secretions are produced
- Thickening of bronchial walls
- Secretions pool and are difficult to remove
- Low O2 levels = cyanosis
- Edema
Pathophysiology of Asthma?
- Inflammation of muscosa
- Bronchoconstriction
- Thick mucous in passages
- Air trapping and hyperinflation of lungs
- Collapsed bronchial walls from pt trying to force air out
What is CHF?
- Heart is unable to pump sufficient blood to meet the metabolic needs of the body
- As a result, fluid backs up into the lungs and can cause crackles, and edema
- Pt will not want to lay down because the fluid will cover their lungs making it very difficult to breathe
What is angina?
Increased need for O2 by the heart or blood supply is impaired - causing chest pain
SYMPTOMS:
- Substernal CP, tightness, or pressure in the chest, often radiates to neck or left arm, pallor, diaphoresis, nausea
TREATMENT:
- ASA prevents clots, makes blood move easier
- Nitro- dilates blood vessels
What is normal ETCO2?
35-45 mmHg
What does an ETCO2 of <35 mmHg mean?
Hyperventilation and Hypocapnia
What does an ETCO2 of >45 mmHg mean?
Hypoventilation and Hypercapnia
Causes of hypoventilation:
- Overdose
- Sedation
- Intoxication
- Postictal states
- Head trauma
- Stroke
- Tiring CHF
- Fever
- Sepsis
- SOB
Causes of hyperventilation:
- Anxiety
- Bronchospasm
- Pulmonary embolus
- Cardiac arrest
- Hypotension
- Decreased CO
- Cold
Indications for STEMI Hospital Bypass Protocol?
- ≥ 18 years old
- Chest pain or equivalent consistent with cardiac ischemia or myocardial infarction
- Time from onset to current episode of pain is < 12 hours
- 12 lead shows 2mm of elevation in V1-V3, 1 mm in other leads: at least 2 contiguous leads OR
- 12 lead ECG computer interprets a STEMI and paramedic agrees
Contraindications to STEMI Hospital Bypass Protocol?
- CTAS 1 and paramedic is unable to secure airway
- 12 lead consistent with LBBB, ventricular paced rhythm, or any STEMI imitator
- Transport to PCI is ≥ 60 mins from patient contact
- Complications requiring PCP diversion
- Moderate to severe
respiratory distress or use of
CPAP - Hemodynamic instability or
SBP < 90 mmHg at any point - VSA without ROSC
- Moderate to severe
- Complications requiring ACP diversion
- Ventilation inadequate
despite assistance - Hemodynamic instability
unresponsive to ACP
management - VSA without ROSC
- Ventilation inadequate
What do we need to tell the PCI centre:
- That the pt is STEMI positive
- Pt’s initials
- Pt’s age
- Pt’s sex
- Paramedics concerns regarding clinical stability
- Infarct territory and/or findings on ECG
- ETA
- Catchment area of pt pickup
What should you tell the PCI staff among arrival?
- Time of symptom onset
- Time of ROSC, if applicable
- Hemodynamic status
- Meds given and procedure
- History of MI/PCI/Coronary artery bypass graft, if applicable
- A copy of qualifying ECG
- A copy of ACR
What do we do as soon as a STEMI is confirmed?
Apply defib pads due to the potential for lethal cardiac arrythmias
If IV access is obtained, which arm is preffered?
Left arm
If ECG becomes positive en route to a non-PCI destination, can we still consider them for STEMI Hospital Bypass?
YES!
Once an advanced airway is in place what happens with compressions and ventilations?
Compressions become asynchronous and ventilate a rate of 1 breath every 6 seconds.
Joule settings for pt’s ≥ 24 hours to < 8 years?
Initial Dose: 2J/kg
Subsequent Doses: 4J/kg
Joule settings for ≥ 8 years old
120J, 150J, 200J
What are signs of ROSC?
- Sudden increase in ETCO2
- Spontaneous respirations
- Palpable pulses
- Change in colour
- Spontaneous movement
What do you do if you obtain a ROSC?
- Complete assessment of C-A-B
- 12 lead
- Full set of vitals
- ROSC MD
- Reassess and treat findings
What do you do if you had a ROSC and your pt re arrests en route?
- Resume CPR immediately
- Pull over
- Initiate an immediate rhythm interpretation
- Treat accordingly
- Continue transport to ER
When must the ambulance be stopped for defibrillation?
When using semi-automated rhythm analysis, the ambulance must be stopped to minimize artifact and risk of an inaccurate rhythm interpretation.