Curriculum Update: Endocrinology, Gastrointestinal Disorders, RenalUrology Disorders

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Curriculum Update Endocrinology,
Gastrointestinal Disorders, Renal/Urology
Disorders

• Condell Medical Center
• EMS System
• March, 2007
• Site Code 10-7200E-1207

S. Hopkins, RN, BSN, EMT-P
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Objectives

• Upon successful completion of this module, the
  EMS provider should be able to
• identify the function of the endocrine system
• distinguish a variety of medical disorders of the
  endocrine system
• describe pain for gastrointestinal and
  genitourinary disorders
• identify and appropriately state interventions
  for a variety of EKG rhythms
• successfully complete the quiz with a score of
  80 or better

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Endocrine System

• Composed of glands that secrete hormones into the
  circulatory system
• Helps regulate various metabolic functions
• Hormones function in a lock and key fashion
• All hormones operate
  within a feedback system

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Hormones

• Act on target organs elsewhere in the body
• Controls and coordinates wide spread processes on
  organs, tissues, or general effects on the entire
  body
• homeostasis
• reproduction
• growth development
• metabolism
• response to stress

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Endocrine Glands

• Hypothalamus
• located deep within the cerebrum of the brain
  serves as connection between the central nervous
  system (CNS) and endocrine system
• secretes hormones that make other endocrine
  glands secrete hormones
• Pituitary - anterior posterior
• located in the brain size of a pea
• secretes hormones essential to growth,
  reproduction, and water balance in the body

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Endocrine Glands contd

• Thyroid
• 2 lobes located in anterior neck
• plays important role in controlling metabolism
• Parathyroid
• normally 4 glands found next to thyroid gland
• secretes hormone to increase blood calcium levels

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Endocrine Glands contd

• Thymus gland
• located in mediastinum behind sternum
• during childhood secretes a hormone critical in
  maturing T lymphocytes (cells responsible for
  cell-mediated immunity)
• Pancreas
• located in upper retroperitoneum behind stomach
• secretes digestive enzymes for digestion of fats
  proteins
• controls production or inhibition of the hormones
  glucagon insulin

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Endocrine Glands contd

• Adrenal gland
• located on superior surface of each kidney
• adrenal medulla - secretes the catecholamine
  hormones epinephrine norepinephrine
• adrenal cortex - secretes 3 steroidal hormones
• Gonads
• chief responsibility for sexual maturation or
  puberty and subsequent reproduction
• ovaries produce eggs
• testes produce sperm

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Regulation of Hormone Secretion

• Hormones operate within a positive or negative
  feedback system to maintain homeostasis
• Negative feedback
• Most common feedback mechanism
• Usually refers to an increase in the serum level
  of hormone or hormone-related substance that
  suppresses further hormone output
• Hormone production is stimulated when the serum
  levels fall

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Negative Feedback Mechanism
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Specific Disorders of the Endocrine System

• Disorders of the endocrine system arise from
• the effects of an imbalance in the production of
  one or more hormones
• the effects of an alteration in the bodys
  ability to use the hormones produced

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Specific Disorders of the Endocrine System

• Clinical effects of endocrine gland imbalance are
  determined by
• the degree of dysfunction
• the age and gender of the affected person

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Disorders of Thyroid Gland

• Usually seen more as part of the medical history
  than as a medical emergency
• Complications of thyroid disorders more likely to
  be seen
• hyperthyroidism - too much thyroid hormone in the
  blood (goiter)
• thyrotoxicosis - prolonged exposure to excess
  thyroid hormones (Graves disease)
• hypothyroidism - inadequate thyroid hormone
• myxedema - long term exposure to inadequate
  levels of thyroid hormones

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Graves Disease

• A type of excessive thyroid activity
  characterized by a generalized enlargement of the
  gland (goiter), leading to a swollen neck and
  often protruding eyes (exophthalmos)
• More common in women than men (6 times)
• Typical onset young adulthood (20s 30s)
• May be due to an autoimmune process
  in which an antibody stimulates the
  thyroid cells
• Strong hereditary role in
• predisposition of the disorder

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Graves Disease

• EMS significance
• cardiac dysfunction the most common EMS event
• tachycardia or new-onset atrial fibrillation in
  absence of cardiac history
• Other signs symptoms
• agitation, emotional changeability, insomnia,
  poor heat tolerance, weight loss with increased
  appetite, weakness, dyspnea

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Thyrotoxicosis

• A term that refers to any toxic condition that
  results from prolonged excess thyroid hormone
• Thyroid storm is a heightened and
  life-threatening manifestation of thyroid
  hyperfunction
• A relatively rare condition can be fatal
• Usually associated with exposure to physiological
  stress (trauma, infection)
• signs symptoms indicate extreme hypermetabolic
  state (high fever (1060F), irritability, delirium
  or coma, tachycardia, hypotension, vomiting,
  diarrhea)
• EMS care - supportive, rapid transport

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Myxedema

• Rare condition of long term exposure to
  inadequate levels thyroid hormones
• x4 more common in women
• Low metabolic state with poor organ function
• Lethargy, cold intolerance, ? mental function,
  puffy face, thin hair, pale cool skin
• Triggers for myxedema coma
• infection, trauma, cold temp

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Myxedema Coma

• Myxedema coma difficult to identify
• EMS impact
• Heart failure not uncommon
• Focus on maintenance of ABCs
• Monitor pulmonary and cardiac systems closely
• Rapid transport important
• Active rewarming in field not indicated
• may cause cardiac dysrhythmias
• vasodilation may cause cardiovascular collapse

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Disorders of Adrenal Glands

• Adrenal cortex - outer portion of adrenal gland
• Secretes steroidal hormones
• glucocorticoids - increase blood glucose levels
• mineralocorticoids - contributes to salt fluid
  balance
• androgenic hormones - influences similar to the
  gonads (role in puberty and reproduction)
• Two medical emergencies of the adrenal cortex
• Cushings syndrome
• Addisons disease

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Cushings Syndrome

• Caused by an abnormally high circulating level of
  corticosteroid hormones produced naturally by the
  adrenal glands
• May be produced
• Directly by an adrenal gland tumor
• By prolonged administration of corticosteroid
  drugs (ie prednisone, hydrocortisone)
• By enlargement of both adrenal glands due to a
  pituitary tumor
• Relatively common problem of adrenals

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Adrenal glands
Adrenal glands
Kidneys
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Cushings Syndrome

• Characteristic appearance
• Face appears round (moon-faced) and red
• Trunk tends to become obese from disturbances in
  fat metabolism buffalo hump on back
• Limbs become wasted from muscle atrophy
• Mood swings , impaired concentration
• Purple stretch marks may appear on the abdomen,
  thighs, and breasts
• Skin often thins and bruises easily
• Weakened bones are at increased risk for fracture

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Moon Face
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Cushings Syndrome Signs Symptoms
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Management Cushings Syndrome

• FYI higher incidence of cardiovascular disease
• stroke
• hypertension
• Fragile skin
• caution with IV starts
• handle the patient carefully to avoid trauma to
  their skin
• Treat symptoms as presented

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Addisons Disease

• Pathophysiology
• Adrenal steroids reduced
• Glucocorticoids
• Mineralocorticoids
• Androgens
• Most common cause is idiopathic atrophy of
  adrenal tissue (cause unknown)
• Less common causes include hemorrhage,
  infarctions, fungal infections, auto immune
  disease, therapy with steroids (ie prednisone)

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Addisons Disease

• Signs and symptoms
• Progressive weakness, fatigue
• Decreased appetite weight loss
• Hyperpigmentation of skin, especially over
  sun-exposed skin areas
• Disturbances in water electrolyte balance
• Low blood volume
• EKG changes
• Abrupt stoppage of steroids may trigger
  Addisonian crisis with cardiovascular collapse

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Addisons Disease

• Management
• Evaluate ABCs correct issues
• Cardiac status - watch for dysrhythmias and
  circulatory collapse
• Fluid resuscitation
• Respiratory status - evaluate SaO2 levels
• Blood glucose levels
• Hypoglycemia very common

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Diabetes Mellitus

• Disease marked by inadequate insulin activity in
  the body
• Glucose is important to all body cells but
  critical for the brain
• Glucose only substance used by the brain for
  energy
• Insulin maintains normal blood glucose levels
• Enables body to store energy as glycogen, protein
  fats
• Action of insulin allows glucose to flow into
  cells

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Normal Blood Glucose Levels

• Healthy persons
• Overnight fast - 80-90 mg/dL
• 1st hour after a meal - 120-140 mg/dL
• lt80mg/dL reflects hypoglycemia
• gt140 mg/dL reflects hyperglycemia
• Intervention necessary
• Hypoglycemia -blood glucose lt60 mg/dL
• Hyperglycemia - blood glucose gt300mg/dL not
  uncommon

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Type I Diabetes

• Low or absent production of insulin in the
  pancreas
• Too much sugar, not enough insulin
• Patients require supplemental insulin
• If untreated, glucose levels rise
• excess glucose spills into urine patient loses
  large amounts of water (becomes dehydrated)
  fatty acids used as energy source resulting in
  ketosis from fat catabolism

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Untreated Type I Diabetes

• Signs symptoms due to elevated blood glucose
  levels
• Polydipsia (constant thirst)
• Polyuria (excessive urination)
• Polyphagia (ravenous appetite)
• Weakness
• Weight loss
• Above signs symptoms are what usually prompt
  people to seek a medical checkup for not feeling
  well

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Type II Diabetes

• More common than Type I diabetes (90 of cases)
• Moderate decline in insulin production and
  inefficient use of the insulin that is produced
• Risk factors heredity, obesity
• Treatment dietary changes, increased exercise,
  oral hypoglycemics (to stimulate insulin
  production), possible addition of insulin if
  necessary

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Diabetic Ketoacidosis (Diabetic Coma)

• Too much sugar, not enough insulin
• Onset slow (12 - 24 hours)
• Increased urination dehydration (warm, dry skin)
• Excessive hunger and thirst
• Tachycardia weakness (volume depletion)
• Ketoacidosis ? Kussmauls respirations (deep and
  rapid) to exhale CO2 (an acid)
• Decline in mental function
• Low potassium - cardiac dysrhythmias

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Diabetic Coma - Hyperglycemia

• ABCs addressed
• Search for medic alert bracelet or insulin in
  refrigerator
• Blood glucose levels (not uncommon to be gt300)
• Fluid resuscitation to treat dehydration
• The higher the glucose level, the more critical
  the situation and the sicker the patient

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Insulin Shock - Hypoglycemia

• Too much insulin, not enough sugar
• Onset rapid
• Bizarre, unusual, inappropriate behavior
• Diaphoretic, tachycardic
• Seizures at critically low glucose levels
• Rapid recovery with correct treatment
• supplemental glucose

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Insulin Shock - Hypoglycemia

• ABCs addressed
• Search for medical alert bracelet or insulin in
  refrigerator
• Treated when blood sugar drops below 60
• IV access to administer dextrose
• Adult - D50 (50 ml)
• Child (1to 15) - D25 (2 ml/kg)
• Child lt1 - D12.5 (4 ml/kg)
• 11 dilution of D25 and normal saline
• Lack of IV access
• Glucagon IM adult 1 mg peds 0.1 mg/kg (max 1mg)

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Glucagon vs Dextrose

• Glucagon
• a hormone, not a sugar
• helps release stores of sugar if there is any in
  the liver but does not supply sugar itself
• What do I do if no IV access, glucagon given,
  patient remains with altered level of
  consciousness and now I get an IV???
• Recheck the glucose level and if indicated,
  administer dextrose IVP

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Gestational Diabetes

• Onset can occur during pregnancy
• While pregnant, most women require 2-3 times more
  insulin than would usually be required when not
  pregnant
• During pregnancy, must be treated with insulin vs
  oral medication
• insulin does not cross placental barrier, oral
  medication does
• After delivery blood glucose levels return to
  normal

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Skill Review

• Precision
• Xtra
• Glucose Monitoring System

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Precision Xtra Calibration

• Done when every new bottle opened
• Calibration strip remains with those strips
• Machine turns on when calibration strip slid into
  monitor
• Confirm that LOT number displayed matches LOT
  number on strips
• Turn monitor off
• Monitor preprogrammed to display in English and
  results in mg/dL

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Precision Xtra Glucose Testing

• Insert glucose strip into monitor
• Verify machine on lot number correct
• Obtain blood sample
• hang hand dependently
• cleanse area with alcohol wipe, let air dry
• Use lancet to prick finger
• use site on ulnar side of finger (easier for
  patient to hold hand in good position to obtain
  sample)

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Precision Xtra Glucose Testing

• Touch blood drop to target area on strip
• blood may be applied to edge or top of test strip
• continue touching the test strip to blood drop
  until monitor begins test (--- shows)
• a second drop of blood may be applied, if needed,
  up to 30 seconds after 1st drop
• Monitor turns off automatically after 30 seconds
• View ( record) your results

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Now You Know

• Your Precision Xtra strips are designed to give
  accurate results based on capillary samples
• You cannot be using venous samples (ie from IV
  starts)
• Venous results will be inaccurate

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Gastrointestinal System
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Gastrointestinal Emergencies

• GI system includes from the mouth to anus and all
  parts in between
• Risk factors for disease (usually self-induced)
• excessive alcohol consumption
• excessive smoking
• increased stress
• ingestion of caustic substances
• poor bowel habits
• Pain is the hallmark of acute abdominal problems
• visceral, somatic, or referred

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Visceral Pain

• Caused by inflammation, distention (inflation of
  the organ), or ischemia (inadequate blood flow)
• Pain vague, dull, or crampy
• Is generally diffuse and difficult to localize
• Examples (most often hollow organs)
• gallbladder (cholecystitis)
• appendix (appendicitis)
• Presentation (from sympathetic stimulation)
• nausea vomiting
• diaphoresis
• tachycardia

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Somatic Pain

• Produced by bacterial or chemical irritation of
  nerve fibers in the peritoneum (peritonitis)
• Is usually constant and localized to a specific
  area
• Often described as sharp or stabbing
• Examples
• ruptured appendix
• perforated ulcer
• inflamed pancreas
• Peritonitis can lead to sepsis death

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Somatic Pain

• Presentation
• Patient often hesitant to move
• Lies on their back or side with legs flexed to
  prevent additional pain from stimulation of the
  peritoneal area
• Often exhibits involuntary guarding of the
  abdomen
• Rebound tenderness often noted during the
  physical examination

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Referred Pain

• Pain in a part of the body considerably removed
  from the tissues that cause the pain
• Results from neural pathways from various organs
  passing thru or over a region where the organ was
  initially formed in fetal stage
• Examples
• diaphragm injury refers pain to neck or shoulders
• dissecting abdominal aneurysm refers pain between
  shoulder blades
• appendicitis refers pain to periumbilical area
• gallbladder refers pain to right shoulder

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Referred Pain Anterior View
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Referred Pain Posterior View
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Disease Entities

• Upper GI Disease
• Gastroenteritis
• Gastritis
• Peptic ulcer disease
• Lower GI Disease
• Colitis
• Crohns disease
• Diverticulitis
• Bowel obstruction

• Other Organ Disease
• Appendicitis
• Cholecystitis
• Pancreatitis
• Acute hepatitis

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Gastroenteritis

• Inflammation of the stomach and intestines that
  accompanies numerous GI disorders
• Causes
• bacteria or viral infections, chemical toxins,
  and other conditions
• Signs and symptoms
• anorexia (loss of appetite), nausea, vomiting,
  abdominal pain
• Management
• supportive

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Gastroenteritis

• EMS personnel who are working in disaster areas
  should observe the following guidelines
• Avoid patient contact if you are ill
• Know the source of water supplies or drink hot
  beverages brisk-boiled or disinfected
• Avoid habits that facilitate fecal-oral/mucous
  membrane transmission (keep your hands away from
  your mouth and nose)
• Observe BSI precautions, especially gloves
• Practice diligent handwashing procedures

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Gastritis

• An acute or chronic inflammation of the gastric
  mucosa
• Causes
• hyperacidity
• alcohol or drug ingestion
• infection
• Signs and symptoms
• epigastric pain
• nausea and vomiting
• bleeding

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Peptic Ulcer Disease

• Erosions in the GI tract from gastric acid
• Duodenal ulcers - most frequently in proximal
  duodenum
• most common 25-50 years old in those under
  stress
• pain at night when stomach empty
• Gastric ulcers - in the stomach
• more common over 50 years old in jobs of
  physical activity
• usually no pain at night pain on full stomach

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Peptic Ulcer Disease

• Causes of peptic ulcer disease
• H. pylori infection (treated with antibiotics)
• Nonsteroidal anti-inflammatory drug use
• aspirin, Motrin, Advil
• Acid stimulating products
• alcohol, nicotine
• Acid secreting tumor
• Zollinger-Ellison syndrome

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Colitis

• An inflammatory condition of the large intestine
  characterized by severe diarrhea and ulceration
  of the mucosa of the intestine (ulcerative
  colitis)
• Incidence - most often 20-40 year olds
• Cause is unknown
• Signs and symptoms
• Nausea, vomiting, weight loss
• Significant pain - cramping colicky
• Grossly bloody stools or stool containing mucus

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Crohns Disease

• A chronic, inflammatory bowel disease thought to
  be of autoimmune etiology, usually affecting the
  ileum, the colon, or both structures
• Exact cause unknown
• Most prevalent in white females, those under
  stress, and in the Jewish population
• The diseased segments associated with Crohns
  disease may be separated by normal bowel segments
  or skip areas
• Formation of fistulas from the diseased bowel to
  the anus, vagina, skin surface, or to other loops
  of bowel are common

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Crohns Disease

• Signs and symptoms
• GI bleeding
• frequent diarrhea
• abdominal cramping
• diffuse abdominal pain
• nausea/vomiting/diarrhea
• fever and chills
• weakness, anorexia, weight loss

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Diverticulitis

• A diverticulum is a sac or pouch that develops in
  the wall of the colon
• Common development with advancing years
• Associated with diets low in fiber
• Diverticulitis is inflammation of diverticula
• Signs and symptoms
• Fever, anorexia, nausea, lower left
  sided pain, bright-red rectal bleeding
• Complications
• Hypovolemic shock and sepsis

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Bowel Obstruction

• A partial or complete blockage of the large or
  small intestines
• Causes
• adhesions, hernias, fecal impaction, polyps,
  tumors
• Signs and symptoms
• decreased appetite, nausea and vomiting, diffuse
  abdominal pain, constipation, and abdominal
  distention
• If untreated can lead to death

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Appendicitis

• A common abdominal emergency that occurs when the
  opening between the lumen of the appendix and the
  cecum is obstructed by fecal material or from
  inflammation from viral or bacterial infection
• Signs and symptoms
• early abdominal pain is diffuse, colicky, in
  periumbilical area (later RLQ), abdominal
  tenderness guarding, nausea,
  vomiting, chills, low-grade fever,
  anorexia
• If ruptured, risk of peritonitis

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Cholecystitis

• Inflammation of the gallbladder, most often
  associated with the presence of gallstones
• Incidence
• more common in women 30-50
• Signs symptoms
• pain, often colicky, in RUQ with referral to
  right shoulder
• pain often after high fat content meal
• nausea, vomiting common
• pale, cool, clammy skin (sympathetic response)
• Giving Morphine may increase spasms

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Pancreatitis

• Inflammation of the pancreas
• Alcoholism causes 80 of cases in USA
• Signs and symptoms
• severe abdominal pain
• localized to LUQ or referred to back or
  epigastric area
• nausea and uncontrolled vomiting retching
• abdominal tenderness and distention
• fever, tachycardia, diaphoresis
• sepsis shock possible, 30-40 mortality

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Acute Hepatitis

• Inflammation of the liver
• Signs symptoms related to severity of disease
• Associated with the sudden onset of malaise,
  weakness, anorexia, intermittent nausea and
  vomiting, and dull right upper quadrant pain or
  referral to right shoulder
• Usually followed within 1 week by the onset of
  jaundice of skin sclera, dark urine, clay
  colored stool

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Risk Factors for Hepatitis A

• Spread by fecal-oral route
• Health care practice without BSI precautions
• Household or sexual contact with an infected
  person
• Living in an area with HAV outbreak
• Traveling to developing countries
• Poor handwashing hygiene practice especially
  after toileting
• Disease often self-limiting, lasts 2-8 weeks, low
  mortality rate

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Risk Factors for Hepatitis B

• Serum hepatitis transmitted as bloodborne
  pathogen - can stay active in body fluids outside
  body for days
• Health care practice without BSI precautions
• Infant born to HBV infected mother
• Engaging in sex with infected partners and/or
  multiple partners
• Drug use by injection
• Patients receiving hemodialysis
• Incidence ? with ?vaccine use

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Risk Factors for Hepatitis C

• Health care practice without BSI precautions
• Blood transfusion recipients before July 1992
• Engaging in sex with infected partners and/or
  multiple partners
• Drug use by injection
• Patients receiving
  hemodialysis
• 1 reason for liver transplant
  need in USA
• Currently no vaccine

1991
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Abdominal Pain - What Could
It Be?

• Naval area
• small intestine
• appendix
• Upper middle abdomen (called epigastric area)
• stomach disorders
• Left upper quadrant
• uncommon area for pain
• colon, stomach, spleen, pancreas
• Right upper quadrant
• gallbaldder, liver

• Lower middle abdomen
• colon disorder
• for women UTI, PID
• Lower left abdomen
• lower colon
• Lower right abdomen
• colon, appendicitis
• Right shoulder
• gallbladder
• Between shoulder blades
• pancreas

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Assessing Abdominal Pain

• Onset - when did it begin
• Provocation/palliation - what makes the pain
  worse/better
• Quality - described in the patients own words
• Region/radiation - if the patient can use one
  finger the pain is localized if the patient rubs
  their hands over the general entire abdomen it is
  diffuse
• Severity - on a scale of 0-10 (0 being no pain
  and 10 being the worse)
• Time - how long has the pain been present?

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Management GI Problems

• Majority of care is supportive and aimed at
  treating signs and symptoms presented
• Position of comfort with ability to protect
  airway in the case of vomiting
• Abdominal pain control - need to contact medical
  control for medication orders
• IV to replace fluid loss (vomiting, diarrhea,
  internal hemorrhage)
• Shock (hypovolemic, septic) possible and then
  aggressive care rapid transport required

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Renal/ Urology System

• Functions of the urinary system
• maintains blood volume
• maintains proper balance of water, electrolytes
  and pH
• retains key compounds in the bloodstream
• excretes waste
• controls arterial blood pressure
• Leading causes of end-stage renal failure
• poorly controlled diabetes
• uncontrolled or inadequately controlled ? B/P

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Renal Calculus (Kidney Stones)
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Renal Calculus

• Crystal aggregation in kidneys collecting system
• Severe pain due to movement of stone through the
  urinary system
• Kidney stones recognized as one of the most
  painful of human problems
• Pain starts subtle and quickly escalates

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Kidney Stone

• Pain starts vague over 1 flank quickly becomes
  sharp in flank and radiating down and toward
  groin
• Patient agitated, uncomfortable, restless
• Skin cool, pale, clammy
• B/P and heart rate elevated due to pain
• Nausea vomiting due to pain

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Management Kidney Stones

• Majority of care is supportive and aimed at
  treating signs and symptoms presented
• Position of comfort with ability to protect
  airway in the case of vomiting
• Flank pain - need to contact medical control for
  medication orders (ie morphine)
• (Abdominal/Flank Pain SOP)
• If patient is unstable with B/P lt100mmHg,
  establish IV sites and give fluid challenge (200
  ml increments)

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Prevention Strategies for Renal Calculus

• Increase water consumption
• Take daily supplements of Vitamin B6 and
  magnesium (to reduce formation of oxalates)
• Avoid foods that raise uric acid levels (ie
  anchovies, sardines)
• Reduce uric acid by eating a low-protein diet
• Limit salt intake to reduce the level of calcium
  oxalate in the urine
• Avoid foods containing calcium oxalate (ie
  chocolate, celery, grapes, strawberries, beans,
  asparagus

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Rhythm Identification

• What is this rhythm?
• What is your intervention?

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Ventricular Tachycardia

• If stable with pulse
• Amiodarone 150 mg diluted in 100 ml D5W IVPB over
  20 minutes
• or (EMS choice)
• Lidocaine 0.75 mg/kg IVP bolus
• Contact Medical Control for further bolus/drip
  orders
• If no pulse - treat like ventricular fibrillation
• emphasis on good quality CPR
• switch CPR compressor every 2 minutes to keep CPR
  effective
• all shocks given at max joules singular

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Rhythm Identification

• What is this rhythm?
• What intervention is necessary?

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Ventricular Fibrillation

• If arrest lt4-5 minutes, CPR until defibrillator
  ready
• If arrest gt4-5 minutes, CPR for 2 minutes
• Single shocks at max output of unit
• Epinephrine 110,000 1 mg every 3-5 minutes
• EMS choice of one antidysrhythmic
• Amiodarone 300 mg rapid IVP 1st dose
• repeat 150 mg IVP in 5 minutes (2nd dose)
• Lidocaine 1.5 mg/kg IVP 1st dose
• repeat 0.75 mg/kg in 5 minutes (2nd dose)

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Rhythm Identification

• What is this rhythm?
• What intervention is necessary?

89
Third Degree Heart Block

• If stable patient - monitor
• If unstable patient narrow complex (QRS)
• Atropine 0.5 mg rapid IVP
• May repeat every 3-5 minutes to max of 3mg
• TCP if Atropine not effective
• If unstable patient wide complex (QRS)
• Begin TCP (Valium for comfort)
• If TCP ineffective, then Atropine 0.5 mg repeated
  every 3-5 minutes to a max of 3 mg
• When theyre alive, give them 0.5

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Rhythm Identification

• What is this rhythm?

91
Third Degree Heart BlockComplete

• In bradycardias, always need to ask 2 questions
• 1 - Is the patient stable or unstable?
• Stable needs monitoring
• Unstable needs intervention
• 2 - Is the QRS narrow or wide?
• Narrow treated initially with Atropine
• Wide treated initially with TCP

92
Rhythm Identification

• What is this rhythm?
• What intervention is necessary?

93
Second Degree Type II

• If stable patient - monitor
• If unstable patient narrow complex (QRS)
• Atropine 0.5 mg rapid IVP
• May repeat every 3-5 minutes to max of 3mg
• TCP if Atropine not effective
• If unstable patient wide complex (QRS)
• Begin TCP (Valium for comfort)
• If TCP ineffective, then Atropine 0.5 mg repeated
  every 3-5 minutes to a max of 3 mg
• When theyre alive, give them 0.5

94
Rhythm Identification

• What is this rhythm?
• What intervention is necessary?

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Second Degree Type I - Wenckebach

• If stable patient - monitor
• If unstable patient narrow complex (QRS)
• Atropine 0.5 mg rapid IVP
• May repeat every 3-5 minutes to max of 3mg
• TCP if Atropine not effective
• If unstable patient wide complex (QRS)
• Begin TCP (Valium for comfort)
• If TCP ineffective, then Atropine 0.5 mg repeated
  every 3-5 minutes to a max of 3 mg
• When theyre alive, give them 0.5

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Rhythm Identification

• What is this rhythm (the patient has no pulse)?
• What intervention is necessary?

There is no pulse!
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PEA (rate under 60)

• Emphasis will be on good quality CPR
• CPR is 302 (compressions to ventilations)
• After intubation, breaths delivered once every
  6-8 seconds, compressor doesnt stop
• Search for causes (6 Hs, 5 Ts) treat them!
• Epinephrine 110,000 1 mg every 3-5 minutes
• If rate lt60, Atropine 1 mg every 3-5 minutes (max
  3 mg)
• If rate gt60, just Epinephrine good CPR

98
Questions ??