Paramedic Crash Course Flashcards
1
Q
Bioavailability
A
-the amount of a drug that enters central circulation and is able to cause an effect.
2
Q
Bolus
A
-administration of medication in a single dose(as opposed to an infusion)
3
Q
Concentration
A
-for calculation purposes, this is the total amount of medication available as packaged, e.g., total amount of a drug(mcg, mg, g) in the syringe, ampule, etc.
4
Q
Dose
A
-the drug amount intended for administration.
5
Q
Enteral
A
-delivery of medication through the GI tract(oral, sublingual, rectal)
6
Q
Half-Life
A
-period of time requires for concentration of drug in the body to be reduced by one halfway
7
Q
LD50
A
-lethal dose(LD50) is the amount of an ingested substance(in mg/kg) that kills 50% of a test sample
8
Q
Parenteral
A
-delivery of medication outside the GI tract, e.g., IV, IO, IM, SQ, intranasal
9
Q
Pharmacokinetics
A
-movement of a drug through the body, includes absorption, bioavailability, distribution, metabolism, and excretion
10
Q
Pharmacodynamics
A
-the mechanism of action of a medication
11
Q
Therapeutic Index
A
-the range between minimum effective dose of a medication and the maximum safe dose. The narrower the therapeutic index, the more risk associated with the medication.
12
Q
Volume
A
-for calculation purposes, this is the total amount of fluid available as packaged, e.g., total amount of fluid(ml) in the syringe, ampule, etc.
13
Q
Pure Food and Drug Act(1906)
A
-prevents the manufacture, sale, or transportation of misbranded or poisonous medications
14
Q
Harrison Narcotic Act(1914)
A
-regulates production, importation, and distribution of opiates
15
Q
Federal Food, Drug, and Cosmetic Act(1938)
A
-gives the U.S. Food and Drug Administration authority to oversee the safety of food, drugs and cosmetics
16
Q
Controlled Substances Act(1970)
A
-categorizes controlled substances based on their potential for abuse and potential medical benefits
17
Q
Schedule 1 Drugs
A
-high potential for abuse. No accepted medical use.
Examples: heroin, LSD, ecstasy, peyote
18
Q
Schedule 2 Drugs
A
-narcotics and stimulants with high potential for abuse and severe dependence.
Examples: methadone, morphine, codeine, amphetamine, methamphetamine
19
Q
Schedule 3 Drugs
A
-less potential for abuse, can still cause low physical or high psychological dependence.
Examples: Vicodin, acetaminophen with codeine, ketamine, anabolic steroids
20
Q
Schedule 4 Drugs
A
-low potential for abuse
Examples: Xanax, soma, Valium, Ativan, versed, ambien
21
Q
Schedule 5 Drugs
A
-contains limited quantities of narcotics, such as cough syrups with codeine
22
Q
The Six Rights of Drug Administration
A
- Right patient
- Right drug
- Right time
- Right route
- Right amount
- Right documentation
23
Q
Enteral
A
- through the GI tract
1. Oral
2. Rectal
24
Q
Parenteral
A
- outside of the GI tract
1. Subcutaneous
2. Intramuscular
3. Intravenous
4. Intraosseous
5. Sublingual
6. Nasal
7. Inhaled
25
Liter(measure of volume)
1. 1 Liter = 1,000 milliliters (mL)
| • 1 ml = 1 cubic centimeter (cc)
26
Gram(measure of weight)
1. 1,000 micrograms (mcg) = 1 milligram (mg)
2. 1,000 mg = 1 gram
3. 1,000 grams = 1 kilogram (kg)
4. 1 kg = 2.2 pounds (lbs)
27
Adrenergic
-related to the sympathetic nervous system (think “adrenaline”)
28
Adverse Effect
-unintended effect of a medication administration
29
Agonist
-medication that stimulates a specific response
30
Analgesic
-medication that reduces pain
31
Antagonist
-medication that inhibits a specific action
32
Bolus
-single dose of medication, given all at once
33
Cholinergic
-related to the parasympathetic nervous system(think acetylcholine)
34
Contraindication
-circumstances when a medication should not be used
35
Cumulative Effect
-repeated administration of a medication that produces effects that are more pronounced than the first dose
36
Drug Class
-categorization of medication with similarities or uses
37
Extra Pyramidal
-tremors, slurred speech, restlessness, muscle twitching, anxiety side effects
38
Habituation
-diminishing of a physiological or emotional response to a frequently repeated stimulus, e.g., cigarettes
39
Hypersensitivity
-undesirable reactions produced by the normal immune system, including allergies and autoimmunity
40
Hypertonic Solution
-solution that has a greater concentration of solutes on the outside of a cell when compared with the inside of a cell, causing fluid to move out of the cell
41
Hypotonic Solution
-solution that has a lesser concentration of solutes on the outside of a cell when compared with the inside of a cell, causing fluid to move out of the cell
42
Indication
-circumstances when a medication should be considered
43
Isotonic Solution
-sodium concentration same as intracellular fluid
44
Mechanism of Action
-pharmacological effects of a medication
45
Potentiation
-interaction between two or more medications causing a response greater than the sum of each individual medication
46
Refractory
-resistant to treatment
47
Side Effects
-any unwanted effect of medication administration
48
Therapeutic Action
-desirable effects of medication administration
49
Tolerance
-reduces response to a medication due to repeated use
50
Untoward Effect
-adverse or harmful side effects of medication administration
51
Cellular Respiration
-cellular processes that convert energy from nutrients into adenosine triphosphate (ATP), and then release waste products
52
Exhalation
-the passive part of breathing
53
External Respiration
-oxygen exchange between the lungs and circulatory system
54
Hypoxia
-oxygen deficiency
55
Inhalation
-the active part of breathing
56
Internal Respiration
-oxygen exchange between blood and cells of the body
57
Minute Ventilation
-volume of gas inhaled or exhaled per minute (respiratory rate x tidal volume)
58
Oxygenation
-delivery of oxygen to the blood
59
Ventilation
-the physical movement of moving air in and out of the lungs
60
Airway Structures
1. Upper airway
| 2. Lower airway
61
Upper Airway structures...(x4)
- noise and mouth
- nasopharynx and oropharynx
- Epiglottis
- Larynx(portion above the vocals chords)
*The oropharynx houses the tongue(primary cause of upper airway obstruction in unresponsive patients)
62
Lower Airway
- larynx(portion below the vocal chords)
- Trachea
- left and right mainstem bronchi
- bronchioles
- alveoli
*alveoli are the “terminal” (end) structure in the lower airway
63
Regulation of ventilation? x4
1. Hypoxia
2. CO2 drive
3. Hypoxic drive
4. Acid base disorders
64
Early signs and symptoms of hypoxia:
```
Early:
-restless, anxious, irritable
-tachycardia and tachypnea
Late:
-decreased LOC
-severe dyspnea
-cyanosis
-bradycardia(especially in pediatric patients)
```
65
CO2 Drive
- The primary system for monitoring breathing status.
- Monitors CO2 levels in blood and cerebrospinal fluid.
- Chemoreceptors in brainstem detect increased CO2 and rapidly trigger increased respiratory rate.
66
Hypoxic Drive
- Backup system to CO2 drive.
- Monitors oxygen levels in plasma.
- May be present in end-stage COPD patients.
- Prolonged exposure to high concentration oxygen in hypoxic drive patients can cause respiratory depression.
67
Primary respiratory problems due to acid-base disorders...
- RESPIRATORY ACIDOSIS: look for blood gas with low pH and elevated CO2
- RESPIRATORY ALKALOSIS: look for blood gas with elevated pH and low CO2
*A primary respiratory problem presents with PaCO2 less than 35mmHg(alkalosis) OT greater than 45mmHg(acidosis).
68
Primary metabolic problems due to acid-base disorders...
- METABOLIC ACIDOSIS: look for blood gas with low pH and low HCO3 level
- METABOLIC ALKALOSIS: look for elevated pH and elevated HCO3 level
*A primary metabolic problem presents with HCO3 below 22mmHg l(acidosis) or greater than 26mmHg(alkalosis).
69
Normal arterial blood gas values:
- pH: 7.35-7.45
- PaO2: 80-100 mmHg
- PaCO2: 35-45 mmHg
- HCO3: 22-26 mEq/L
- SaO2: 95% OT above
70
Oxygenation
1. Effective ventilation is required for adequate oxygenation.
2. Adequate oxygenation is required for effective respiration.
3. Adequate oxygenation DOES NOT ensure effective internal respiration.
4. Ventilation DOES NOT ensure oxygenation (e.g., ventilation can occur without oxygenation during smoke inhalation or CO poisoning)
5. Delivering supplemental oxygen can only improve cellular oxygenation if ventilations are adequate and result in external and internal respiration.
71
Respiration
- Effective respiration results in cellular exchange of O2 and CO2
- Time and injury
72
Without adequate respiration:
- Heart and brain become irritable almost immediately
- Brain damage likely within 4 minutes
- Permanent brain damage likely within 6 minutes
- Irrecoverable brain damage(biological death) likely within 10 minutes
73
Ventilation perfusion mismatch
1. aka V/Q mismatch or V/Q defect
2. Occurs when the lungs receive oxygen, but not adequate blood flow or when the lungs receive blood flow, but inadequate oxygen.
3. V/Q mismatch could begin as either a ventilatory(oxygenation & respiration) problem or a perfusion problem, e.g., pulmonary embolism.
74
Manual airway techniques comes first;
1. Head-tilt, chin lift (preferred)
| 2. Jaw-thrust (suspected spinal injury)
75
Suction (as indicated) comes second:
1. Rigid suction catheter
| 2. French suction catheter
76
Rigid suction catheter
- used to suction oral airway
| - aka tonsil tip or Yankauer catheter
77
French suction catheter
- used to suction nose, stoma, or inside advanced airway
- aka soft-tip, whistle-tip or flexible catheter
- available in numerous sizes(diameter) (e.g., 3 French through 40 French. Increased number = increased diameter)
78
Suction time cannot exceed:
- 15 seconds for adults
- 10 seconds for pediatrics
- 5 seconds for infants
79
Mechanical airway adjuncts come third(as indicated)
- OPA: for unresponsive patients without a gag reflect(avoid posterior displacement of tongue)
- NPA: can be used on patient with decreased LOC, but not unresponsive
80
Extraglottic, Retroglottic and supraglottic airway device
Common types used prehospital....
- Laryngeal Mask Airway(LMA) and LMA Supreme
- i-gel suprahlottic LMA
- Pharyngeal Tracheal Lumen Airway (PTL)
- Esophageal Tracheal Combitube(ETC)
- King LT Airway
- Supraglottic Airway Laryngoscope Tube (SALT)
81
Extraglottic, Retroglottic and supraglottic airway device
Advantages....
- easy to use
- blind insertion, no laryngoscope needed
- able to insert quickly
- high success rate (avoid posterior displacement of tongue)
82
Endotracheal Intubation (ETT)
Advantages....
- isolates the trachea
- eliminates gastric distention from ventilation
- no mask seal needed
- improved suctioning ability
- route for medication administration (naloxone, epinephrine, atropine, lidocaine)
83
Endotracheal Intubation (ETT)
Disadvantages....
- extensive training required
- direct visualization of vocal chords required
- takes longer than other advanced airways
- has many serious complications
- not been shown to increase survival rates
84
Endotracheal Intubation (ETT)
Verification of proper ETT placement....
- direct visualization of cords
- auscultation of epigastrium and bilateral lung field
- continuous waveform capnography
- pulse oximetry
- esophageal detector device
- ETT introducer
85
Surgical cricothyrotomy
-Only indicates in acute, life threatening situations when use of less invasive airway techniques are ineffective.
86
Rapid Sequence Induction (intubation) or medication-assisted intubation
Indication....
- respiratory failure
- inability to protect airway
- combative patient, suspected TBI
- persistent hypoxia
87
Rapid Sequence Induction (intubation) or medication-assisted intubation
Contraindications....
- respiratory and cardiac arrest
- anticipated difficult airway (relative)
- short transport time (relative)
- ability to manage airway with less invasive measures
- neuromuscular disease, e.g., ALS, muscular dystrophy
88
Predictors of difficult advanced airway insertion
- mouth does not fully open
- hypersecretions
- obesity
- pulmonary edema
- airway burns
- facial trauma
89
Increased Mallampati score (used with oral intubation)
- Class 1: entire tonsil clear
- Class 2: upper half of tonsil visible
- Class 3: soft and hard palate visible
- Class 4: only hard palate visible
90
LEMONS mnemonic for difficult airway
- L: look externally
- E: evaluate 3-3-2 rule
- M: Mallampati score
- O: obstruction
- N: neck mobility
- S: saturations
91
Indications for supplemental oxygen...
- dyspnea
- hypoxia
- pulse oximeter below 94%
- altered or decreased LOC
- respiratory or cardiac arrest
- hypoperfusion(shock)
92
Supplemental oxygen devices....
- nasal cannula
- non-rebreather
- small volume nebulizer(SVN)
93
Nasal Cannula
- low flow oxygen
- up to 6 lpm can be administered
- delivers 24%-44% oxygen (about 4% per liter above 21% room air)
94
Non-rebreather
- high flow oxygen
- 12-15 lpm
- delivers about 90% oxygen
95
Small Volume Nebulizer (SVN)
-used for delivery of aerosolized medication
96
Cylinder Sizes
- D cylinders
- E cylinders
- M cylinders
97
D cylinders
-about 350-liter capacity
98
E cylinder
-about 625-liter capacity
99
M cylinder
-about 3,000-liter capacity
100
Oxygen cylinder pressure
- full cylinder is about 2,000 PSI
| - sage residual pressure is 200 PSI (cylinder should be taken out of service and refilled once it reaches 200 PSI)
101
Calculating duration of an oxygen tank...
(Cylinder PSI - Sade residual pressure) x tank constant / remaining flow rate (lpm) = minutes
102
-D cylinder constant
-0.16
103
E cylinder constant
-0.28
104
M cylinder constant
-1.56
105
Initiate PPV for any patient with signs of inadequate breathing, such as ....
- excessively bradypneic or tachypneic breathing (age dependent)
- shallow breathing
- altered or decreased LOC
- dyspnea
- retractions
- accessory muscle use
- cyanosis
- paradoxical motion
- sucking chest wound
106
Do not hyperventilate, in increases the risk of....
- gastric distention
- vomiting
- aspiration
- ineffective CPR
- death
107
Ventilation for adults....
-10-12 breaths per minute
108
Ventilation for children and infants....
-12-20 breaths per minute
109
Adequate ventilation indication....
- rise and fall of the chest
| - 1 second to inflate the chest during PPV
110
Complications of PPV...
- increased intrathoracic pressure and reduced cardiac output
- gastric distention and increased risk of vomiting
111
Atonal Respirations
-slow, shallow, infrequent breaths; indicates brain anoxia
112
Biot’s Respirations
-irregular pattern of rat and depth and periodic apnea; indicates increased ICP
113
Central neurological hyperventilation
-deep, rapid respirations; indicates increased ICP
114
Cheyne-Stokes respirations
-progressively deeper and faster breaths, changing to slower and shallow breaths; indicates brain injury
115
Kussmaul Respirations
-deep, gasping breaths; indicates possible DKA
116
Rales(crackles)
-fine, bubbling sound on inspiration; indicates fluid in lower airways.
117
Rhonchi
-course sound on inspiration; indicates inflammation or mucus in lower airways
118
Wheezes
-high pitched sound on inspiration or expiration; indicates bronchoconstruction
119
Snoring
-indicates partial airway obstruction from the tongue
120
Stridor
-high pitched sound indicating significant upper airway obstruction (e.g., foreign body, angioedema, anaphylaxis)
121
Gurgling
-indicates fluid in the upper airway
122
Increased/high ETCO2
-possible hypoventilation
123
Decreased/Low ETCO2
-possible hyperventilation
124
ETCO2 drops to 0
-possible for esophageal intubation or displaced tube
125
Sharp drop in ETCO2
-possible pulmonary embolism, cardiac arrest, hypotension, hyperventilation
126
Continuous Positive Airway Pressure(CPAP) indications....
- for alert and spontaneously breathing patients
- at least 12yrs of age
- in significant respiratory distress (ex. sleep apnea, COPD, pulmonary edema, CHF, pneumonia)
- tachypnea
- SpO2 below 94% and it use of accessory muscles
127
CPAP starting range....
-5-7 cm H2O
128
CPAP contraindications....
- apnea
- patients unable to follow verbal commands
- suspected pneumothorax
- chest trauma
- tracheostomy
- vomiting
- GI bleeding
- hypotension
129
Tracheostomy tune/stoma
- BVM will connect directly to trach tube
- to ventilate a patient with stoma (no trach tube) use an infant or person mask with appropriate size BVM. Seal mouth and nose during ventilation.
- trach tubes and stomas require frequent suctioning
130
Foreign body airway obstruction (FBAO)
BLS...
- conscious adult and children(not infants): abdominal thrust
- unconscious (all ages): chest compressions
- conscious infants: back blows and chest thrust
131
Foreign body airway obstruction (FBAO)
ALS (when BLS Interventions are ineffective(
- attempt to remove foreign body with laryngoscope and McGill forceps
- Attempt ETT insertion to try passing tube through obstruction or forcing it into right mainstem
132
Ascites
-abdominal swelling(consider liver disease, CHF, renal failure)
133
Cullen’s sign
-bruising around the umbilicus(consider intra-abdominal bleeding)
134
Field impression
-a field conclusion of the patients problem based on the clinical presentation and the exclusion of other possible causes through considering the differential diagnosis
135
Grey Turner’s sign
-bruising over flanks(consider intra-abdominal bleeding)
136
Pitting edema
-depression left by pressure of finger(consider CHF, renal failure)
137
What are the 5 major components of patient assessment?
- scene size-up
- primary assessment
- patient history
- secondary assessment
- reassessment
138
Scene size-up consist of...
- scene safety
- standard precautions
- mechanism of injury (c-spine indicated) or nature of illness(medical patients)
- number of patients
- additional resources
139
Purpose of the primary assessment is....
-to find and manage immediately life-threatening conditions
140
Components of the primary assessment:
- general impression
- spinal precautions and expose patient as indicated
- level of consciousness (AVPU)
- ABC’s(or CAB, if patient unresponsive)
- rapid scan aka rapid secondary(as indicated)
- transport priority
141
ABC’s....
-AIRWAY
•manual, suction, mechanical
•BLS before ALS
-BREATHING
•support ventilations and provide supplemental oxygen as indicated
•manage flail chest (with PPV) and sucking chest wounds (with occlusive) as indicated
-CIRCULATION
•assess pulse, CPR as indicated
•manage life-threatening bleeding
*direct pressure
*tourniquet
*hemostatic agent if tourniquet not possible (e.g., torso)
•assess circulation to skin (color, temp, moisture)
142
Significant MOIs indicating probable need for high-priority transport to an appropriate trauma center:
- falls over 20 feet in adults or over 10 feet in children
- any fall leading to a traumatic loss of consciousness
- motor vehicle collision (MVC) with more than 12” of intrusion into occupant space
- MVC with ejection
- death of another occupant in same vehicle
- pedestrian or cyclist struck by vehicle
- motorcycle accident over 20 mph
*Two or more significant MOIs significantly risk likelihood of life-threatening injury
143
SAMPLE history...
- Signs and symptoms
- Allergies
- Medications
- Past history
- Last oral intake
- Events leading to incident
144
OPQRST
- Onset
- Provocation
- Quality
- Radiation
- Severity
- Time
145
ASPN...
Associated Symptoms: other symptoms associated with the chief complaint
Pertinent Negatives: potential associated symptoms that are not present
146
Indications for a head-to-toe secondary assessment include...
- unresponsive or otherwise unable to provide feedback
- multisystem trauma
- high priority transport
147
Indications for a focused secondary assessment include...
-conscious patient with a specific, isolated chief complaint (Medical or trauma)
148
Assessment for DCAP-BLS-TIC(trauma/unresponsive patients)...
- Deformities, distention
- Contusions
- Abrasions
- Penetrating injuries, paradoxical movement
- Burns
- Laceration
- Swelling
* Palpate for:
- Tenderness
- Instability
- Crepitus
149
Components of reassessment....
- reassess LOC
- reassess ABCs
- reassess chief complaint
- reassess interventions
- reassess vitals
150
Infants (up to 1 year) normal vital signs....
- RESPIRATIONS: 30-60
- HEART RATE: 100-180
- SYSTOLIC BP: at least 70 to 104
151
Toddlers (1-3 years) normal vital signs...
- RESPIRATIONS: 24-40
- HEART RATE: 80-110
- SYSTOLIC BP: about 80+2 (age in yrs)
152
Preschoolers (3-6 years) normal vital signs...
- RESPIRATIONS: 22-34
- HEART RATE: 70-110
- SYSTOLIC BP: about 80+2 (age in years)
153
School-age (6-12 years) normal vital signs...
- RESPIRATIONS: 18-30
- HEART RATE: 65-110
- SYSTOLIC BP: about 80+2 (age in years)
154
Adolescent (13-18 years) normal vital signs...
- RESPIRATIONS: 12-26
- HEART RATE: 60-90
- SYSTOLIC BP: 110-130
155
Capnography
-measure or monitoring of exhaled CO2
156
Infarct
-area of necrosis, or death
157
Pulse CO-oximetry (SpCO)
-non-invasive measurement of carbon monoxide saturation of hemoglobin
158
Pulse oximetry (SpO2)
-non-invasive measurement of oxygen saturation of hemoglobin
159
SpMet
-non-invasive measurement of methemoglobin
160
Bipolar Leads....
- Lead 1
- Lead 2
- Lead 3
161
Lead 1:
-negative electrode right arm and positive electrode left arm
162
Lead 2:
-negative electrode right arm and positive electrode left leg
163
Lead 3:
-negative electrode left arm and positive electrode left leg
164
ECG changes must occur in at least ___ contiguous leads
-2
165
Ischemia
- Myocardium receiving inadequate oxygen (reversible condition)
- ECG: ST depression, inverted T waves or peaked T waves
*ST depression must be at least one small box below baseline.
166
Injury
- Myocardial damage due to ischemia (potentially reversible condition)
- ECG: ST elevation
*ST elevation must be at least 1 mm in two or more continuous leads or inverted T waves.
167
Infarction
- Myocardial death (irreversible condition)
- ECG: significant (pathological) Q wave
*Pathological Q wave must be at least 1 mm (0.04 seconds) wide or deeper than one-third the R wave (in same lead).
168
Unipolar (augmented) leads...
-aVR, aVL, aVF
169
Chest (precocial) leads...
-V1-V6
170
Lead groupings (“I See All Leads” mnemonic)
- Inferior leads: II, III, aVF
- Septal leads: V1, V2
- Anterior leads: V3, V4
- Lateral leads: V5, V6, Lead I, aVL
171
Pulse Oximetry (SPO2) uses....
- non-invasive and indirect method of monitoring oxygen saturation of hemoglobin(SpO2)
- readings are a %, therefore max value of 100
- can provide info about mechanical cardiac function
*Can be useful in assessing circulation distal to a suspected orthopedic fracture or for identifying inapparent hypoxia in patients with long bone fractures.
172
SpO2 Values....
- Normal: 95%-100%
- below 95%-suspect hypoxia, shock, or respiratory compromise
- below 90%-aggressive airway management, ventilatory support and high flow oxygen indicated
*COPD patients may routinely have SpO2 readings as low as 85%.
173
Inaccurate SpO2 readings possibly due to...
- hypoperfusion(ex. hemorrhage, dehydration, hypothermia)
- Anemia
- CO poisonings (device only reads percentage on bound hemoglobin, not what is bound to that hemoglobin, e.g., O2 vs. CO.)
- Methemoglobinemia/cyanide poisoning
174
ETCO2
-provides real time information regarding cellular metabolism, circulation, and ventilation
175
ETCO2 values....
-Normal ETCO2 = 35-45mmHg
-Elevated ETCO2 = > 45mmHg
• elevated ETCO2 indicates hypoventilation due to: increased CO2 production and/or decreased CO2 elimination
•elevated ETCO2 indicates acidosis
-Decreased ETCO2 (below 35 mmHg)
•decreased ETCO2 indicates hyperventilation due to: decreased CO2 production and/or increased CO2 elimination
•decreased ETCO2 indicates alkalosis
176
Indications and advantages of continuous ETCO2 monitoring....
- continuously monitor ETT
- monitor effectiveness of CPR
- monitor adequacy of ventilations
177
Carbon Monoxide
-Carbon monoxide (CO) bonds to hemoglobin much stronger (200x) than oxygen does, causing carboxyhemoglobin (a common toxicologic emergency)
178
Pulse CO-Oximetry (SPCO) values....
- 0%-3% = normal
- 3%-12% = administer high-flow oxygen and transport if symptomatic, or known exposure to CO
- above 12% = administer high-flow oxygen and transport
179
Indications for glucometry....
- known or suspected diabetic history
- altered or decreased LOC
- seizures
- stroke
- pregnancy
- suspected alcohol abuse
- suspected overdose
- any time you have any reason to remotely suspect an abnormal blood glucose level
180
Blood Glucose values....
- Normal(adult, non-diabetic)-about 70-120mg/dL
- Normal(adult, diabetic)-about 100-180mg/dL
- Normal(newborn)-above 40mg/dL
181
Angioedema
-swelling of the lower layer of skin and underlying tissue. Swelling may occur in the face, tongue, larynx, abdomen, arms and legs. Often associated with urticaria.
182
Compensated Shock
-early shock where the body still maintains adequate perfusion
183
Decompensated Shock
-later shock where the body can no longer maintain adequate perfusion
184
Exsanguination
-severe bleeding, leading to death
185
Hemorrhage
-bleeding
186
Irreversible Shock
-stage of shock leading to inevitable death
187
Mean Arterial Pressure (MAP)
-DBP + 1/3 (SBP - DBP)
188
Multiple organ dysfunction syndrome
-progressive failure of at least two organ systems
189
Urticaria
-hives
190
What can lead to hemorrhagic shock?
-single femur fracture, pelvic fracture, or multiple long bone fractures
191
Signs of internal hemorrhage...
- vomiting blood
- coffee ground like emesis
- blood in stool (hematochezia)
- dark, tarry stool (melena)
- abdominal distention or rigidity
- suspected femur or pelvic fracture
- signs and symptoms of shock
192
Sources of bleeding....
-Arterial, Venous, Capillary
193
Arterial bleeding...
-spurting, bright red blood
194
Venous bleeding
-steady, flowing, dark red
195
Capillary bleeding
-slow, oozing dark red blood
196
Management of external bleeding...
- 1. Direct pressure = consider hemostatic dressings and/or wound packaging per local protocol
- 2. Tourniquet = always place tourniquet proximal to injury, apply enough pressure to control bleeding, do not apply directly over joint, write “TK” and time applied on tape and secure to patients forehead and notify transfer of care personnel
197
Suspected internal bleeding management...
- general management of ALS patients
- treat for shock
- consider pelvic binder for suspected pelvic fracture
- rapid transport
198
Shock....
-(hypoperfusion) is any condition causing inadequate tissue perfusion due to reduced cardiac output
199
What are the three causes of shock...
-pump, pipes, fluid
200
Cardiogenic Shock...
-pump(cardiac) problem
201
Anaphylactic shock....
-pipes(vasodilation) problem
202
Hemorrhagic shock
-fluid(hypovolemic) Shock
203
Impaired oxygenation and glucose (shock)
- All causes of shock lead to impaired oxygenation due to anaerobic (without oxygen) metabolic function
- anaerobic metabolism creates little energy and increased acidosis
- Shock also causes impaired glucose delivery to cells, increasing risk of organ failure
204
Categories (stages) of Shock
- Compensated
- Decompensated
- Irreversible
205
Compensated Shock
-The body’s defense mechanisms are compensating for the decrease in cardiac output.
-Compensatory Mechanisms....
•increased HR and cardiac force of contraction
•increased vasoconstriction
•reduced urinary output to maintain intravascular volume
206
Decompensated (progressive) Shock
-The body’s defense mechanisms are no longer able to compensate for the decrease in cardiac output.
-Falling or low BP are hallmark signs of Decompensated Shock.
-Importance of Mean Arterial Pressure (MAP)
•MAP = DBP + 1/3 (SBP - DBP)
•Normal MAP is 70-100. A MAP of at least 60 is needed to perfuse vital organs
207
Irreversible Shock
-Irrecoverable shock leading to inevitable death.
208
Older Classification (types) of shock system
1. Cardiogrnic shock(pump problem)
2. Hypovolemic shock(fluid problem)
3. Neurogenic shock(vasodilation problem)
4. Anaphylactic shock(vasodilation/permeability problem)
5. Septic shock(vasodilation/permeability problem)
209
Newer Classification (types) of shock system
1. Cardiogenic shock
2. Hypovolemic shock
3. Obstructive shock
•Pulmonary embolism
•Cardiac tamponade
•Tension pneumothorax
4. Distributive shock
•Neurogenic Shock
•Anaphylactic Shock
•Septic Shock
210
Classic signs of shock
1. ALOC progressing to unresponsiveness
2. Tachycardia progressing to absent pulses in Decompensated/Irreversible Shock
3. Pale, cool, clammy skin
4. Normal BP during compensated shock and falling BP during Decompensated shock
5. Differentiating Compensated v. Decompensated Shock
i. S/S of Compensated Shock
• ALOC (restless, anxious, irritable)
• Tachycardia
• Pale, cool clammy skin
• Thirst
• Normal BP
ii. S/S of Decompensated Shock
• Decreased LOC
• Absent peripheral pulses
• Mottling, cyanosis
• Falling BP progressing to hypotension
211
Standard Shock Management
1. Airway management, supplemental oxygen, ventilation support as indicated
2. Control bleeding bad indicated
3. Prevent heat loss(even mild hypothermia increases metabolic demand and inhibits clotting).
4. Rapid transport
5. IV access
6. Consider IV fluids bolus using volume expanders (such as normal saline or lactated ringers).
i. Rule out pulmonary edema before IV fluid challenge.
ii. Fluid bolus not typically indicated for adults with SBP of at least 100 mmHg
iii. If indicated (SBP 90 or below for adults), consider 250 mL fluid bolus.
iv. Burn patients-see chapter
v. Pediatric patients-see pediatric chapter
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Cardiogenic Shock
1. left ventricular failure is the most common cause
2. Signs and Symptoms
•classic signs of shock
•dyspnea and pulmonary edema
•cyanosis
3. Management
•standard shock management
213
Hypovolemic Shock
1. Causes include hemorrhage, vomiting, diarrhea, burns, sweating, DKA
2. Signs and symptoms
i. classics signs of shock
3. Management
i. classic management
ii. IV fluids
•IV fluids indicated for most causes of hypovolemic shock with presenting hypotension
•permissive hypotension, keep BP at around 90 systolic
•pediatric fluid resuscitation, infants at 10mL/kg and pediatrics at 20mL/kg
214
Neurogenic Shock
1. Damage to brain or spinal cord leading to widespread vasodilation and relative hypovolemia.
2. Signs and symptoms
i. Possible paralysis
ii. Possible respiratory compromise
iii. MOI indicative of probable spinal injury
iv. Warm, flushed, dry skin (not pale, cool, clammy skin as usually seen)
v. Hypotension even in early stages of shock
vi. Slow pulse
3. Management
i. Standard shock management
215
The three unique characteristics of neurogenic shock is....
1. Early hypotension
2. Bradycardia
3. Warm, dry skin
216
Anaphylactic Shock
1. Life threatening allergic reaction to an antigen, such as food, meds, venom.
2. Signs and symptoms
i. Skin: flushed, itching, urticaria, angioedema
ii. Respiratory: dyspnea, wheezing, stridor, laryngospasm
iii. Cardiovascular: widespread vasodilation, tachycardia
3. Management
i. Aggressive airway Intervention likely needed due to laryngoscope
ii. High-flow oxygen and ventilators support as indicated
iii. Epinephrine
iv. IV fluids for volume support
v. Consider antihistamines, steroids per local protocols
217
The three acute life-threats caused by anaphylaxis are....
1. Airway compromise(laryngospasm)
2. Respiratory compromise(bronchoconstriction/edema)
3. Circulatory compromise(massive vasodilation)
218
Septic Shock(sepsis)
1. Systemic infection that enters the blood and is carried throughout the body.
2. Signs and symptoms
i. Fever or hypothermia possible
ii. Skin can be flushed, pale, or cyanotic
iii. ALOC
iv. Dyspnea, abnormal lung sounds
v. Tachycardia, hypotension
3. Management
i. Standard shock management and IV fluid support
219
Shock Cycle
1. ⬇️ BP
2. ⬆️ Vasoconstriction
3. ⬆️ Tissue Anoxia
4. Anaerobic Metabolism
5. ⬆️ Lactic Acidosis
6. Damaged Blood Vessel
7. ⬆️ Vessel Permeability
8. ⬆️ Fluid Loss in Tissue
9. ⬇️ Effective Blood Volume
10. ⬇️ Return to Heart
11. Cardiac Output
1. .....
220
Multiple Organ Dysfunction Syndrome
A. Multiple organ failure following conditions such as shock, trauma, burns, surgery, renal failure.
B. Major cause of death following sepsis, significant trauma, and major burns.
C. Early stages present with fever, ALOC, tachycardia, dyspnea.
D. Later stages present with systems failure, moving from pulmonary to hepatic, intestinal, renal and finally cardiac failure , encephalopathy and death.
221
Afterload
-resistance the left heart overcomes during contraction
222
Aneurysm
-a weakening in the wall of an artery
223
Ascites
-edema in the abdomen
224
Cardiac hypertrophy
-enlargement of the heart, often due to hypertension
225
Cardiac output
-volume of blood ejected by left ventricle in one minute(stroke volume x heart rate)
226
Chronotrope
-rate of cardiac contraction
227
Dromotrope
-speed of cardiac conduction velocity
228
Endocarditis
-an infection of the endocardium, usually involving the heart valves
229
Ejection fraction
-percentage of blood ejected from a filled ventricle
230
Failure to capture
-ventricles Gail to respond to an impulse. On an EKG, the pacemaker spike will appear, but it will not be followed by a QRS complex
231
Failure to sense
-pacemaker malfunction that occurs when the pacemaker does not detect the patients Myocardial depolarization. May be seen on an EKG tracing as a spike following a QRS complex to early.
232
Inotrope
-force of cardiac contraction
233
Orthopnea
-difficultly breathing while supine
234
Paroxysmal nocturnal dyspnea (PND)
-acute onset of difficulty breathing at night, usually while sleeping
235
Pericarditis
-inflammation of the pericardium
236
Preload
-volume of fluid returning to the right heart
237
Prinzmetal’s Angina
-variable angina caused by coronary artery spasms
238
Starling’s Law
-the more the heart is stretched (within limits), the greater the resulting force of contraction
239
Stroke Volume
-amount of blood ejected by the left ventricle during one contraction
240
Risk Factors for Heart Disease
1. Smoking
2. Hypertension
3. Age (risk increases w/age)
4. High Cholesterol
5. Diabetes
6. Hereditary
7. Gender (increased risk for males)
8. Substance abuse
9. Lack of exercise
10. Oral contraceptives
11. Stress
241
Layers of the heart?
- Endocardium
- Myocardium
- Epicardium
- Pericardium
242
Endocardium
-innermost layer
243
Myocardium
-muscular wall of the heart
244
Epicardium
-inner layer of the pericardial sac
245
Pericardium
-outer layer of the pericardial sac
246
Oxygen rich blood exits the ____ side of the heart through the _____.
-left and aorta
247
The aorta branches off into _____, then _______, and finally ________.
-arteries, arterioles, capillaries
248
On the venous side, capillaries feed into ______, then _____, and finally the superior or inferior ____ _____.
- venules and veins
| - vena cava
249
Arteries always carry blood _____ from the heart.
-away
250
Veins always carry blood _____ the heart.
-towards
251
Pulmonary artery is the one artery in the body that carries __________ blood.
-deoxygenated
252
The pulmonary vein is the only vein in the body that carries __________ blood.
-oxygen-rich
253
Systemic vascular resistance (SVR)......
-is the resistance to blood flow throughout the body(excluding the pulmonary system).
254
SVR is determined by.....
-the size of the vessels
255
Construction of blood vessels ________ SVR and can cause an _______ in blood pressure.
-increase and increase
256
Dilation of blood vessels ________ SVR and can cause an _______ in blood pressure.
-decrease and lower
257
Preload
-the pre-contraction pressure based on the volume of blood coming back to the heart. Increased preload increased stretching of the ventricles and increased myocardial contractility.
258
Afterload
-the resistance the heart must overcome during ventricular contraction. Increased afterload decreases cardiac output.
259
The heart receives its own blood supply through the _______ ________ during diastole.
-coronary arteries
260
Main branches of Left Coronary Artery(LCA)?
-Left Anterior Descending and Left Circumflex artery
261
LCA perfuses.....
-left ventricle, interventricular septum, portion of the right ventricle and the cardiac conduction system
262
Main branches of the Right Coronary Artery(RCA)?
-posterior descending artery and the right marginal artery
263
RCA perfuses.....
-part of the right atrium and ventricle, part of the conduction system
264
Sinoatrial(SA)node.....
-the hearts primary conduction system. Typically generates electrical impulses between 60-100 bpm.
265
Atrioventricular(AV) junction.....
-the hearts first backup pacemaker. Typically generates electrical impulses between 40-60 bpm.
266
Bundle of His....
-the hearts final pacemaker. Typically generates electrical impulses 20-40bpm.
267
Common signs and symptoms of Cardiac emergencies....
- chest pain/pressure
- dyspnea
- palpitations
- diaphoresis
- restlessness/anxiety
- feeling of impending doom
- nausea/vomiting
- weakness
- edema
- syncope
- denial
268
Acute Coronary Syndrome(ACS) includes....
- angina
- unstable angina
- acute myocardial infarction
269
Angina(stable angina)
- transient chest pain due to myocardial ischemia
- often provoked my exertion or stress
- typically last less than 30 minutes and resolved with rest or nitroglycerin
270
Unstable angina
- new onset angina
- angina for at least 20 minutes while at rest
- frequent angina episodes or increasing duration of angina
271
Acute Myocardial Infarction (AMI)
-irreversible necrosis of myocardial muscle and diagnosed by ECG changes and elevated myocardial blood enzymes
AMI classifications is based on ECG findings
-st elevation MI (STEMI)
-Non ST elevation MI (NSTEMI)
*use caution when considering nitroglycerin in suspected right ventricular inferior MI (risk of profound hypotension)
272
Left heart failure (CHF)
- left ventricular dysfunction causes backpressure into pulmonary circulation
- dyspnea and pulmonary edema are common with left heart failure
- myocardial infarction is a common cause of left heart failure
273
Right heart failure (CHF)
- right ventricular dysfunction causes backpressure into systemic venous circulation
- JVD and pedal edema are common with right heart failure
- left heart failure is the most frequent cause of right heart failure
274
Signs and Symptoms of CHF
- pulmonary edema (typically left heart failure)
- dyspnea (typically left heart failure)
- paroxysmal nocturnal dyspnea (typically left heart failure)
- orthopnea (typically left heart failure)
- mottled skin
- weakness
- ascites (typically right heart failure)
- JVD (typically right heart failure)
- bilateral pedal edema (typically right heart failure)
- patients with a history of CHF are often prescribed medications such as digoxin(positive inotrope), a diuretic(furosemide), ACE inhibitor, and a potassium supplement
275
Cardiac Tamponade
-excess fluid accumulation in the pericardial sac impairing diastolic filling and reducing cardiac output. Can be caused by trauma or medical related.
276
Signs and Symptoms for cardiac tamponade....
- chest pain
- dyspnea
- Beck’s Triad: JVD, narrowing pulse pressure, muffled heart tones
277
Note:
-For any patient with JVD and clear lung sounds, be alert for possible right ventricular infarct, pulmonary embolism, or cardiac tamponade.
278
Hypertensive Emergency signs and Symptoms
- elevation in blood pressure(>180/120) with some sort of target organ change, such as: ALOC, headache, dyspnea, chest pain, vomiting, visual disturbance, pulmonary edema, ECG changes, symptoms of stroke, seizures
- history of hypertensive disorder
- noncompliance with anti-hypertensive meds
- pregnancy(preeclampsia and pregnancy induced hypertension)
- nosebleed
279
Abdominal Aortic Aneurysm(AAA)
- often occur in the abdominal region, but also can develop along the thoracic aorta(thoracic aortic aneurysms), or in the brain(cerebral aneurysm).
- the weakened wall of the affected artery is prone to rupture and massive bleeding
280
Signs and Symptoms of AAA
- most common in older males
- tearing back pain
- possible history of hypertension, smoking, atherosclerosis, family history of AAA
- possible pulsating abdominal mass
- varying blood pressures between left and right arm of (at least 15-20 mmHg)
- signs and symptoms of hypovolemic shock(if ruptured)
281
Management of AAA
- general management of ALS patients
- keep patient still
- caution when palpating abdomen
- transport rapidly to appropriate facility with surgical capabilities
282
Carcinogenic Shock
- persistent, severe left ventricular pump failure despite correction of existing dysrhythmias, hypovolemia, or widespread vasodilation.
- frequently caused by massive MI; can also be caused by tension pneumothorax or cardiac tamponade
283
Signs and Symptoms of cardiogenic shock
- hypotension(May be <80 mmHg systolic)
- tachycardia
- chest pain
- dyspnea
- ALOC
- weakness
- history of trauma or MI
284
Management of Cardiogenic Shock
- manage ABC’s
- position of comfort if possible
- oxygen as indicated
- consider CPAP
- consider vasopressor medication, such as dopamine
- rapid transport to appropriate facility
285
Rate of chest compressions
-100-120 per minute adult or peds
286
Depth of compressions for Adults
-2-2.4”
287
Depth of compression for children
-2”
288
Depth of compressions for infants
-1.5”
289
Adult compression to ventilation ratio
-30:2(one or two rescuers)
290
Infant and child comp: ventilation ratio
—30:2(one rescuer); 15:2(two rescuers)
291
Ventilation rate with advanced airway
- Adults = 10/minute
| - Peds = 12-20/minute
292
Amiodarone or lidocaine May be used for VF or pulseless VT after CPR, defibrillatation, and epinephrine
-
293
Atropine indicated for symptomatic bradycardia (ALOC, chest pain, hypotension)
-
294
Consider dopamine and epinephrine infusion or transcutaneous external pacing (TEP) for symptomatic bradycardia unresponsive to atropine
-
295
Consider immediate TEP for symptomatic bradycardia with Hugh-degree AV Block when IV access delayed
-
296
12-lead ECG should be obtained prehospital for suspected acute coronary syndrome to assess for STEMI
-
297
Acute respiratory distress syndrome(ARDS)
-non cardiogenic pulmonary edema
298
Cot pulmonale
-right sided heart failure
299
Hemoptysis
-coughing up blood
300
Orthopnea
-difficultly breathing while laying down
301
Paroxysmal nocturnal dyspnea
-difficultly breathing at night
302
Positive end expiratory pressure (PEEP)
-extrinsic PEEP uses an impedance valve to increase volume of air remaining in lungs at end of expiration to improve gas exchange
303
Subcutaneous emphysema
-crackling under the skin upon palpation due to trapped air. Typically found in chest, neck or face.
304
Tidal volume
-volume of air exhaled or inhaled with each breath
305
Upper Airway consist of.....
-nasopharynx, oropharynx, larynx(above the vocal cords)
306
Lower airway consist of....
-larynx(below the vocal cords), trachea, bronchi, alveoli
307
Ventilation
-is the mechanical process that moves air in and out of the lungs
308
Inspiration
-the active process of ventilation (requires energy)
309
Exhalation
-the passive process of ventilation
310
External respiration
-movement of oxygen from the alveoli into the bloodstream and movement of CO2 from the blood stream to the alveoli
311
Internal respiration
-the exchange of gases (O2 and CO2) between the bloodstream and the tissues in the body
312
Tidal volume
-normal adult tidal volume is about 500ml
313
Minute volume
-respiratory rate x tidal volume
314
Signs and Symptoms of Respiratory Compromise
- positional breathing(tripod)
- skin color changes(cyanosis)
- ALOC
- difficultly speaking full sentences
- difficultly breathing
- accessory muscle use(nasal flaring, intercostal retractions, tracheal tugging)
- abnormal respiratory rate or tidal volume
- SpO2 below 95%
- abnormal lung sounds
315
GENERAL MANAGEMENT OF RESPIRATORY COMPROMISE
- Manage ABCs as indicated
- Monitor SpO2.
- Monitor ETCO2 as indicated.
- Monitor ECG.
- Provide supplemental oxygen if hypoxia suspected and as indicated to maintain SpO2 of at least 95%.
- IV access, as indicated.
- Support ventilations as indicated (adjust rate of ventilations to target ETCO2 of 35–45 mmHg).
- Consider causes, e.g., various respiratory or cardiac problems, trauma, sepsis, etc.
- Consider CPAP as indicated.
- Consider pharmacologic interventions as indicated.
- Transport
316
Acute respiratory distress syndrome (ARDS)
-ARDS is a form of pulmonary edema not caused by poor left ventricular function. There are many causes, including sepsis, trauma, OD, drowning, and toxic inhalation.
317
Signs and symptoms of ARDS
```
-Progressive decline in respiratory status
Note: Acute onset respiratory failure in healthy patient may indicate high-altitude pulmonary edema (HAPE).
-Dyspnea
-ALOC, such as agitation, confusion
-Fatigue
-Pulmonary edema (rales bilaterally)
-Tachypnea
-Tachycardia
-Possible cyanosis
-Low SpO2”
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