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EMS 150 Lesson A
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Course Overview
• Assessment Flowchart
• Assessment Inventory
• Underlying Theme
• Circulation (Shock / Types of Shock)
• Ventilation
• Oxygenation
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Lesson A Overview
• Assessment Skills
• Emergent / Immediate Interventions
• Circulation-Ventilation-Oxygenation
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Flowchart
• Is this a “code” (cardiac arrest)?
• CVO assessment
• Immediate interventions?
• Focused H&P to drive a differential Dx list
• Ddx drives specific interventions / plan of care
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Inventory
• All of the things you MUST consider
• Determine WHICH you will do / utilize
• Few patients need ALL of these things
• Prioritize / delegate
• Gather data / toss out noise / get information
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CVO
• Major Body Processes
• Must Circulate blood
• Must Ventilate air for gas exchange
• Must Oxygenate the blood to be circulated
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Circulation• Shock defined
• Obstructive Shock defined
• Hypovolemic Shock defined
• Cardiogenic Shock defined
• Distributive Shock defined
• Assessment options (pulses, skin, HR, BP)
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Ventilation
• Rate of breathing
• Effort / work of breathing
• Depth of breathing (“dead spacing”)
• EtCO2 as a tool
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Oxygenation
• Adequate O2 content inspired
• Intact process in alveoli for gas exchange
• Assessment challenges (SpO2 limitations)
• Lung Sounds assessment
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Lab A
• Pulse oximetry
• Capnography
• ECG limb leads
• BP via auscultation, palpation, doppler, use of machine pressures
• Lung Sounds auscultation
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More for Lab A
• Two-thumbs down / BVM ventilation
• Oxygen Therapy
• PEEP via BVM, CPAP, BiPap
• Nebulizer treatments
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Pulse Oximetry
• Not real time—may be 1-2 minutes old
• Signal strength is key to check before you start believing the number (match to pulse)
• Requires adequate perfusion—patient with SpO2 of 60 and BP of 60 example
• Can be fooled by Carbon Monoxide (CO)
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Capnography
• Real time—no delay
• Requires adequate metabolism to make CO2 at the cells
• Requires adequate circulation to bring back CO2 to the lungs
• If those two are intact, shows you ventilation data—number and waveform shape matters
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HR and Breathing
• Radial pulse palpation is a great 1st step
• Touch is good (let’s you feel skin)
• Look at the patient’s breathing rate, effort and depth while holding their pulse
• Presence lets you estimate BP
• Rate and Regularity gives you data on Heart
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Blood Pressure
• Size and place the cuff
• Auscultate when you can hear
• Palpate when you cannot hear but can feel a pulse
• Doppler when you cannot hear or feel a pulse
• Machines don’t forget to take it or what it was
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Two-Thumbs Down
• Big muscles of your hands make the seal
• Jaw thrust at the same time
• Very important
• Takes skill—more than squeezing a bag!
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BVM Ventilation• Do NOT use too much volume—hurts BP
• DO get normal chest rise
• Adult BVM holds 1500 cc!!!!!
• Looking for tidal volume of 300-500 for most adults—taller needs more
• ONLY use two hands when you need more pressure (think about why)—not volume
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Oxygen Therapy
• “Normal” varies if patient has lung disease
• Target is 94-99% for those without lung disease
• Adjust your target downward for lung disease
• 90-95% may be their norm
• 5% below “normal”
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O2 Tools
• Nasal cannula at 2-3 liters per minute for 2-3 minutes should raise the SpO2 by 2-3 points.
• If you need more than 2-3 points, use the NRBM.
• If the SpO2 is not rising toward “normal” with cannula as above, consider why…may be a ventilation problem??
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PEEP
• Recruits all available alveoli into the game
• Reduces work of breathing—prevents atelectasis
• Conscious patients may not like the tight-fitting mask at first
• Raises intra-thoracic pressure which may reduce preload (reduce BP)
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CPAP or BiPAP
• Continuous Positive Airway Pressure
• Bi-level Positive Airway Pressure
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Nebulizer Tx
• Makes tiny droplets out of the medication
• Patient can hold or can be attached to a mask
• Can use with CPAP / BiPAP mask usually
• Beware of dead-spacing