EMS

Question 1

When do you do CPR?

Answer 1

You do CPR when someone is in cardiac arrest

cardiac arrest = typically from electrical disturbance in the heart

Symptoms - no breathing or agonal breathing, unconscious, unresponsive, and no pulse

Question 2

How do you do CPR?

Answer 2

Yell for help, call 911, yell for someone to get AED
Do 30 chest compressions (100-120 BPM)
Do 2 rescue breaths
Keep cycling until AED arrives
As soon as AED arrives - check rhythm
Follow instructions (rhythm shockable or non shockable
After AED does it’s thing do 2 minutes of CPR until AED prompts you again

Question 3

How would you reverse an oversedated patient? How does this medication work?

Answer 3

Flumazenil Package: 1 mg/10 mL

• Dose: 0.2mg (2cc), then 0.3mg (3cc), then 0.5mg (5cc) at 1 minute increments IV
• Max dose 1.0 mg
• Duration: 30-60 min
• Onset 1-3 min

IF resedation occurs, may repeat doses at 20-min intervals; not to exceed 1 mg/dose or 3 mg/hr

Flumazenil is a benzodiazepine antagonist. It competitively inhibits the activity of benzodiazepine and non-benzodiazepine substances that interact with benzodiazepine receptors site on the GABA/benzodiazepine receptor complex.

Question 4

How do you check for fit of a nasopharyngeal airway? When do you use a nasopharyngeal airway?

Answer 4

Can be used in conscious or semiconscious patients who have intact cough and gag reflex

Use the diameter of victims smallest finger as a guide

Should measure from tip of nose to earlobe

Question 5

How do you check for fit of a oropharyngeal airway? When do you use a oropharyngeal airway?

Answer 5

Used on unconscious patients only
Place OPA against side of face
Want it to reach from corner of the mouth to the angle of the mandible

Question 6

How do you reverse someone given too much opioid?

How does this medication work?

Answer 6

Naloxone (Narcan): reversal for Narcotics

• Package: 0.4mg/1mL
• Dose: 0.4-2mg IV
• Max dose: 10 mg
• Duration: 15 min, monitor patient for re-sedation
• Onset: 1 min

MOA: naloxone antagonizes the opioid effects by competing for the same receptor sites. Because the duration of action of naloxone is generally shorter than that of the opiate, the effects of the opiate may return as the effects of naloxone dissipate.

It has a half-life of 30 to 120 minutes, depending on the route of administration, with IV being the fastest.

Question 7

How is epinephrine package in our clinic?

Answer 7

1 mg/mL (1:1000 dilution)

Question 8

A patient has acute substernal crushing chest pain, jaw pain, squeezing, tightness, pressure. What is it?

Answer 8

-Sit or stand as patient choses
- 100% Oxygen, 10 L/min
- Nitroglycerine tab (0.4mg) or spray sub-lingual
- Repeat q 3-5 minutes x 3
- Avoid in patient taking Viagra, Cialis, Levitra within last 24 hrs
- If pain not relieved by nitroglycerin:
o Consider event to be an MI
o Continue Oxygen
o Nitrous oxide
o Aspirin (160-325mg)-non-enteric coated
o EMS
- If pain stops, patient may go home
- EMS if 1st ever chest pain episode

Question 9

Prolonged, oppressive pain or unusual discomfort in the center of the chest behind the breastbone. Pain radiating to the shoulder, arm, neck, or jaw. Pain or discomfort accompanied by sweating, nausea, vomiting, and shortness of breath. Symptoms sometimes subside and then return

What is it?

Answer 9

Heart attack
- Administer Oxygen 00% Oxygen, 10 L/min and Aspirin (325 mg)
- Consider MONA (Morphine, Oxygen, Nitroglycerin, Aspirin)
o Morphine 2-5 mg every 5-30 minutes; do not administer if respirations less than 12/min; can also use N2O (35% N2O/65% oxygen)
Nitroglycerine tab (0.4mg)

Question 10

Patient feels lightheaded, dizzy, unsteady, nauseous, heart palpatations, weak, and is having changes in vision. What is it? What brings it on?

Answer 10

Syncope.
- Seat the patient
- Have them lower their head between their knees to increase blood flow to the head
- If a person faints, position them in Trendelenburg position with head turned to one side
Alert EMS, if person regains consciousness, keep them quiet and lying down for at least 15 minutes or until EMS arrives. Check blood sugar.

Syncope - caused by a temporary drop in the amount of blood that flows to the brain.

Vasovagal syncope - due to changes in nervous system, some of these situations are: Dehydration, Intense emotional stress, Anxiety, Fear)

Orthostatic hypotension - Postural syncope is caused by a sudden drop in blood pressure due to a quick change in position, such as from lying down to standing.

Question 11

Seizure

Answer 11

• Prevent injury, remove objects from mouth, gently restrain
• Verify patent airway during/after
• Benzodiazepine IM or IV at 5 minute mark
  o Midazolam 5mg IM
  o Diazepam 5-10mg IV or IM
  o Lorazepam 4mg IV
• Apply pulse oximeter
• Oxygen
• Diabetic? Consider Hypoglycemia
• Beware of hypoxia during/after
• Risk of hypoventilation post-seizure

Question 12

Hyperventilation

Answer 12

• Breath slowly into paper/plastic bag
  NO Oxygen

rate of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood. The body normally attempts to compensate for this homeostatically, but if this fails or is overridden, the blood pH will rise, leading to respiratory alkalosis.

Question 13

Laryngospasm

Answer 13

spasm of the vocal cords that temporarily makes it difficult to speak or breathe

sudden onset, and just as suddenly, it goes away, usually after a few minutes. The breathing difficulty can be alarming, but it’s not life-threatening.

• Remove any obvious foreign material
• Ventilate forcefully with oxygen: 10L/min
  Reverse sedative agent

Question 14

Fatigue, Pale skin, Shakiness, Anxiety, Sweating, Irritability, Confusion, blurred vision, Seizures, Loss of consciousness, altered mental status, feeling of impending doom

Answer 14

Hypoglycemia
- Blood sugar <70mg/dl (normal BS=70-110) - usually symptomatic at 50-60 mg/dL

Giving a patient 1 g of carbohydrate to raise blood glucose 5 mg/dL. Try to give patient 15 g.
- Conscious: give oral sugar (soda (4-6 oz), juice, cake icing (4 tsp))
- Semi-conscious: avoid oral liquids (cake icing)
- Unconscious: cake icing or parenteral agent
o 50% dextrose IV (give 30 mL of dextrose to give 15 g of sugar directly to blood stream)
o 1mg glucagon IM
o 0.3mg EPI IM
- Oxygen (nasal cannula) wait 15-30 min
- Seizure may occur
- EMS if not resolved

Question 15

Wheezing, cough, dyspnea, increased anxiety

Answer 15

ATHSMA ATTACK

• Allow patient to sit as they please, upright preferred
• Administer Albuterol prn, 5 min onset (Beta-2 agonist inhaler: bronchodilator)
• Re-administer as necessary
• 100% Oxygen 10 L/min
• Epinephrine 0.3mg IM if not responsive to Albuterol
• EMS if symptoms do not resolve or if 1st episode

Question 16

skin rash, angioedema, wheezing, laryngeal edema, hypotension

Answer 16

Anaphylaxis reaction

Epinephrine 0.3mg-0.5mg IM or sub-cutaneous

• We have EPI in 1mg/1ml vials for 1:1000. So draw up .3mL for anaphylaxis)
• Repeat EPI q5min
• 100% Oxygen at 10 L/min
• EMS
• Diphenhydramine (Benadryl) 50mg IM or IV
• Hydrocortisone 100mg

child dose is 0.3 mg if they are 6-12 years old, over 12 years old if they are pre-pubertal

under 6 years old = 0.15 mg

Question 17

Both hands on neck

Answer 17

Choking
- Universal sign:  both hands on neck
- Heimlich maneuver if person is standing
	o Quick upward thrusts
	o Repeat at least 5 times
- If person collapses
o Chest compressions

Question 18

Pale, cold skin, rapid pulse, quick shallow breathing and weakness

Answer 18

Shock

• Have person lie or sit down
• Keep them comfortable
• Place on side if they are unconscious
• EMS if not resolved

Question 19

How do opioids work?

Answer 19

Opioids bind to G-protein coupled receptors to cause cellular hyperpolarisation.
Most opioid analgesics bind to receptors in the central and peripheral nervous system in an agonist manner to elicit analgesia.
Opioid receptors: Mu, delta, & kappa-receptors. Activation of these receptors produces analgesia.

Effects: analgesia, sedation, constipation, euphoria, respiratory depression, miosis (pupillary constriction), antitussive

physical dependence (the physical adaptation to the substance associated with symptoms of tolerance and withdrawal) and psychological dependence (substance-seeking behavior in response to biochemical changes in the brain from continued exposure to the substance; often referred to as “addiction”) are consequences of opioid use

Full agonists
Morphine, heroin
Methadone
Meperidine
Codeine
Fentanyl

Partial agonist
buprenorphine

Mixed agonist/antagonists
Butorphanol
Nalbuphine
Pentazocine

Full antagonists
Naloxone
Naltrexone
Methylnaltrexone

Pain relief primarily via the two following mechanisms:
Raising the pain threshold
Change in pain perception

ceiling effect describes the pharmacological phenomenon that once the therapeutic limit is reached, an increase in dose will no longer increase the functional response, but only the side effects.

Full opioid receptor agonists (e.g., morphine) have No ceiling effect
Increase in dose always leads to increased functional response and there is no cut-off point.
Partial opioid receptor agonists (e.g., buprenorphine)
have a Ceiling effect
At a certain point, an increase in dose does not increase the functional response, but only the side effects.
Relative analgesic potency [9]
The analgesic potency of opioids is described in relation to morphine, which, accordingly, has the analgesic potency of 1. Higher relative analgesic potency allows for lower doses achieving the same analgesic effect.

Question 20

how do benzodiazepines work?

Answer 20

Benzodiazepines bind at the interface of the GABA-A receptor and subsequently lock the receptor into a configuration that increases its affinity for GABA. Benzodiazepines do not alter the production, release, or metabolism of GABA but instead potentiates its inhibitory actions by augmenting or enhancing receptor binding. This binding ultimately increases the flow of chloride ions through the GABA ion channel, causing postsynaptic hyperpolarization, which decreases the ability to generate an action potential. The low incidence of respiratory depression with benzodiazepines, which differentiates it from barbiturates, is related to the low density of binding sites in the brainstem, which houses the respiratory center.