rwj mhs education program - rwjuh-ems.orgnancy caroline’s emergency care in the streets, 6th...

Welcome to

RWJ MHS Education Program (formerly known as “Competencies”)

Hamilton, New Brunswick and Somerset Campuses January – March 2015

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Please review this presentation in preparation for the education session in which you plan to participate. Time to complete this should be about 30 minutes. (Your eyesight is not failing….some of the graphics are a bit blurry.) This material is not divided into BLS or ALS…topics solely within the ALS scope of practice should be obvious. Since patients and their caregivers don’t read the certification patch on our uniforms, they neither note nor probably care who is an EMT, MICN or MICP…they just know we are the help they called for. We work as team….BLS providers are encouraged to review the ALS material. Anticipating what your ALS team members will do and your role in continuing your care can add to the efficiency of patient care. There is a lot to be done to take care of these patients and to interact with their caregivers.

A copy of these PowerPoint slides will be available at each

Education session

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This presentation contain 2 parts

Part I – Congestive Heart Failure

Part II – Pneumothorax

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03.10.03 Universal Patient Care – Assessment

Universal – MICU Use

Universal – Vascular Access

03.10.04 Airway Management

Airway-Intubation Protocol

Airway – Facilitated Intubation Protocol

03.10.19 Respiratory Distress – Pulmonary Edema

03.10.22 Trauma

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You might find it helpful to review these RWJ Pediatric Patient Care Protocols

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You might also find it helpful to review the sources used to prepare this presentation

Nancy Caroline’s Emergency Care in the Streets, 6th Edition, 2008. Jones and Bartlett Publishers Inc. and American Academy of Orthopaedic Surgeons Prehospital Emergency Care, 10th Edition, 2014. Joseph J. Mistovich and Keith J. Karren Prehospital Trauma Life Support, 7th Edition, 2011. Mosby, Inc. .

Part I Congestive Heart Failure

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Definition

Review of A&P

Causes

Signs and Symptoms

Treatment BLS, ALS

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Heart in an ineffective pump

Too fast, too slow or too weak to empty its chambers and provide adequate cardiac output

As a result, blood backs up into the systemic system, the pulmonary system or both

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Definition

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Review of A&P

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Review of A&P

Left-Sided Failure

The left atria receives oxygenated blood from the pulmonary veins and moves it to the left ventricle. When the left ventricle…a powerful pump…is weakened, stiff, thickened or over stretched, it cannot pump all of the blood in its space out to the aorta. As result, the blood in the left atria does not empty and starts to back up into the pulmonary veins and the lungs. The alveoli within the lungs then fill with the backed up blood, especially the liquid component (plasma or serum), resulting in pulmonary edema. The oxygen that entered the lungs and alveoli is blocked from getting out of the alveoli and into the blood vessels to the left atria.

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Review of A&P

Right-Sided Failure

Often, but not always, occurs as a result of left-sided failure. As blood backs up from the left side of the heart and lungs, the right side of the heart has to work harder to pump deoxygenated blood into the lungs against the increased pressure of the pulmonary arteries. As a result the right ventricle becomes weakened, stiff, thickened, or overstretched. The right aria cannot handle the backup from the right ventricle and blood trying to enter the heart from the body (via the vena cavae) also starts to back up. The pressure in the blood vessels causes them to become engorged. As the vessels’ pressure increases, the blood, especially the liquid component (plasma or serum), leaks into the tissue, causing edema.

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Review of A&P

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Review of A&P

Heart failure causes a complex series of events that affect not only the heart, but also kidneys, blood pressure, liver function, and more. Here is a diagram that starts the explanation.

Acute:

MI (can affect right side and/or left side)

Use of certain drugs

Virus, bacteria (myocarditis, endocarditis)

Cardiac trauma

Non-compliance with medications to control CHF

Non-compliance with diet (i.e. low sodium) to control CHF

Chronic

Hypertension

Coronary artery disease

Previous MI

Heart valve dysfunction

Natural part of the aging process

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Causes

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Signs and Symptoms

EMS is often called because of difficulty breathing caused by CHF.

Pulmonary Edema may or may not be present.

Remember to access for chest pain, possible MI.

Position of function (normal mental status); usually sitting up with legs dependent (if safe to do so)

Oxygen: 10-15 lpm via NRB, as tolerated

Ventilation: assist as necessary

CPAP (PEEP) 10 cmH2O if any one:

Resp rate ≥26

Signs of resp distress, regardless of rate

SpO2≤ 94 with NRB

If SBP ≥ 100:

NTG 0.4mg every 5 minutes

Furosemide 20mg IV/IO (if fluid overload is certain)

12 Lead, STEMI Protocol, if indicated

Endotracheal Intubation (facilitated, RSI)

And more….. Review RWJ Adult patient Care Portocols 03.10.04, 03.10.19

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Treatment

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End of Part I……. So, take a deep breath and on Part II.

Part II Pneumothorax

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Definition

Review of A&P

Causes

Signs and Symptoms

Treatment BLS, ALS

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Presence of air outside the lung and within the pleural space

Hemothorax often, but not always, present

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Definition

Closed - a hole in the lung. The outside chest wall is intact. As the patient inhales or is ventilated with a BVM, air exits through the hole and into the pleural space

Open (“sucking” chest wound) – a hole on the outside of the chest wall that allows air to enter and exit the pleural space from the outside with ventilatory effort.

A combination of both open and closed – a hole in the lung and the outside chest.

Bilateral – hole in both lungs and/or both sides of the chest wall

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Definition - Types

Simple – (open or closed) the hole(s) are not so big as to

pose an immediate life threat. Tension - As amount of air on the affected side increases, the

lung on the affected side can “collapse” under the pressure. As the amount of air and pressure further increases, the

heart and great vessels (vena cavae, aorta, and family), and unaffected lung can be pushed to the unaffected side.

The pressure (tension) around the heart, great vessels and unaffected lung can be so great as to prevent the heart from pumping, the great vessels from filling/emptying, and the unaffected lung from expanding.

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Definition - Severity

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Review of A&P

Closed Open Closed Tension

Chest Trauma

Any disease that causes stiff or weakened lung tissue, especially emphysema

BVM/Mechanical Ventilation

Can be spontaneous (classic is thin, tall male, age 18-20, with sudden shortness of breath)

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Causes

These may be acute or progressive or stable

Agitation, discomfort

Dyspnea, use of accessory muscles

Diminished breath sounds on affected side

Tachycardia

Pale skin, cool, diaphoretic

Normal to low BP

Lowered PaO2 (< 94)

Open: hole in chest, air makes sucking noise on inhalation

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Signs and Symptoms

As it progresses…..

If receiving manual ventilation, increasing resistance if felt when squeezing the BV device

Altered Mental Status

Cyanosis

Grossly diminished or absent breath sounds on the injured side

JVD (may not be present if hypovolemic due to trauma)

Hypotension

Trachea deviates away from affected side as tension develops (this is a late sign, and difficult to discern in patients with short, thick or muscular necks)

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Signs and Symptoms

If hole on outside chest wall: cover wall with occlusive dressing…secure on 3 sides

Position of function: air rises, blood follows gravity Trauma: if appropriate, elevate head of board Non-Trauma: sitting up, position of patient comfort

Oxygen 10-15 lpm via NRB Assist ventilations, if indicated. Monitor resistance felt with BV device. If tension pneumothorax, perform Chest Needle Decompression, if all 3 are

present: 1. Severe respiratory distress

• Cyanosis and/or SpO2 ≤90% with NRB, BVM or ET

2. Diminished/absent breath sounds on affected side 3. SBP <90, ALS

IV/IO fluid to maintain SBP ≥90 and HR <120, 1L max. Pain and SBP ≥90

Morphine Sulfate 0.1mg/kg to 10mg max OR Fentanyl 1mcg/kg to 100mcg max

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Chest Needle Decompression

2nd or 3rd Intercostal space, midclavicular line on the affected side

Thanks for your time…..see you at the Education Session!

Please bring your questions, comments, education and experience.

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End of Part II – Pneumothorax

rwj mhs education program - rwjuh-ems.orgnancy caroline’s emergency care in the streets, 6th...

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