Medical I Refresher Lecture

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Medical I Refresher Lecture

• Aaron J. Katz, AEMT-P, CIC
• www.es26medic.net

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Pharmacology

• The study of drugs
• Sources, characteristics and effects
• Always refer to drugs as medications

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• EMTs can deliver some medications and can assist
  the patient in delivering some other medications

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Meds EMTs can deliver

• Oxygen
• Oral Glucose
• Activated Charcoal
• Epinephrine injectors (EpiPen)
• Aspirin

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Meds that EMTs can assist

• Prescribed inhalers
• Nitroglycerin

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Drug Names

• Chemical
• Generic
• E.g. Ibuprofin, Nitroglycerin
• Trade
• E.g. Advil, Nitrostat

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Important terms

• Action
• The therapeutic effect that a drug is expected to
  have on the body
• Indications
• Signs/Symptoms/Conditions for which a particular
  medication should be used
• Contraindications
• Signs/Symptoms/Conditions or patient for which a
  particular medication should NOT be used
• Side effects
• Any actions of a medication other than the
  desired ones

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Drug Administration

• Before administering any drug, know the four
  rights
• Right patient
• Right medication
• Right dose
• Right route

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Medication Routes

• Intravenous (IV)
• Oral (PO)
• Sublingual (SL)
• Intramuscular (IM)
• Intraosseous (IO)
• Subcutaneous (SC)
• Transcutaneous
• Inhalation
• Rectal (PR)

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References

• PDR
• USP
• Merck Manual
• The Pill Book
• Not an official guide, but a very good source
• ePocrates

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• Survey of commonly used drugs

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Anti-hypertensives
Accupril Cozaar Isoptin (Verapamil)
Lotensin Monopril Norvasc
Lopressor (Metoprolol) Toprol XL Tenormin (Atenalol)
Vasotec Zestril Calan (verapamil)
Prinivil
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Diuretics

• Lasix (Furosemide)
• Bumex
• Diazide
• HCTZ
• Hydrodiuril

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Combination HTN, diuretics

• Zestoretic
• Prinzide
• Vasaretic

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Potassium supplements

• K-Dur
• K-Tab
• Slo-K

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Cholesterol Lowering

• Lipitor
• Mevacor
• Lopid
• Pravachol
• Zocor
• Crestor

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Antianginals
Procardia XL (Nifedipine) Nitrostat (nitroglycerin)
Cardizem (Diltiazam) Isordil (Isosorbide Dinitrate)
Inderal (propranalol) Imdur (Isosorbide Mononitrate)
Capoten Corgard
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Oral Anti-hyperglycemics
Diabeta (Glyburide) Diabenase
Glucotrol (Glipizide) Glucophage
Glynase (Glyburide) Micronase (Glyburide)
Avandia
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Injected Anti-hyperglycemics

• Humulin
• Humalog
• Lente
• Lantus
• And many others

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Anti-epilepsy

• Dilantin
• Phenobarbitol
• Depakote
• Tegratol
• Nerontin

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Some cardiac meds

• Lanoxin
• Digoxin
• Coumadin
• Warfarin
• Many of the anti-hypertensives and anti-anginals
  are used for cardiac conditions

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Assorted respiratory inhalers

• Atrovent
• Combivent/Duoneb
• Alupent
• Proventil, Ventolin (Albuterol)
• Intal
• Serevant
• Beclovent
• Advair
• Azmacort
• Aerobid

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Respiratory Emergencies
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Review of airway anatomy

• Nose/Mouth
• Oropharynx/Nasopharynx
• Epiglottis
• Trachea
• Cricoid cartilage
• Larynx/vocal cords

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Review of airway anatomy-2

• Bronchi
• Bronchioles
• Lungs
• Alveoli
• Diaphragm

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Physiology

• Inspiration
• Expiration

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Signs of normal breathing

• Normal rate depth
• Regular pattern of inhaling/exhaling
• Good breath sounds bilaterally
• Regular rise and fall of the chest bilaterally
• Some movement of the abdomen

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Signs of abnormal breathing

• RRlt8 or RRgt24
• Excessive respiratory muscle usage
• Pale or cyanotic skin
• Cool, diaphoretic (clammy) skin
• Shallow or irregular respiration
• Pursed lips

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Signs of abnormal breathing

• Pursed lips
• Nasal flaring
• Tripod positioning
• Tachycardia
• Altered mental status (AMS)
• Agitated ? sleepy
• Look for the yawn!

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Some terms

• Dyspnea
• Difficulty breathing
• Shortness of breath (SOB)
• Apnea
• No breathing
• Hypoxia
• Not enough oxygen

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What causes us to breath

• Normal individuals
• Excessive CO2 levels in arterial blood
• COPD patients
• Low levels of O2 in arterial blood
• COPD
• Chronic Obstructive Pulmonary Disease
• Emphysema
• Chronic bronchitis

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Causes of dyspnea

• Obstructed lower airways
• Due to fluid, infection, collapsed alveoli
• Damaged alveoli
• Damaged cilia in lower airways
• Spasms, mucus plugs, floppy airways
• Obstructed blood flow to lungs
• Pleural space filled with air or fluid

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Common respiratory disorders causing dyspnea

• Airway infections
• Acute Pulmonary Edema (APE)
• COPD
• Spontaneous pneumothorax
• Asthma, allergies, anaphylaxis
• Pleural effusion
• Prolonged seizures
• FBAO
• Pulmonary embolism
• Hyperventilation syndrome
• Severe pain

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Infections

• Colds/flu
• Bronchitis
• Bronchiolitis
• Pneumonia
• Croup
• Epiglottitis
• ? History will often tell the story

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Acute pulmonary edema

• Not really a respiratory problem
• A cardiac problem
• Congestive Heart Failure (CHF)
• TBD with cardiac emergencies
• Severe dyspnea
• Pink frothy, blood-tinged sputum

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COPD

• Almost always caused by
• Long-term smoking
• Long term inhalation of bad things
• Chronic bronchitis
• Emphysema

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Chronic bronchitis

• Damaged respiratory pathway cilia
• Excessive mucus production
• Cant cough out effectively
• Very frequent bronchitis/pneumonia

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Emphysema

• Loss of alveolar elasticity and shape
• Air pockets
• Can not expel CO2

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COPD

• Most have elements of both diseases
• Prolonged expiratory phase
• Most common lung sound
• Expiratory wheeze
• Minor respiratory problemd exacerbates COPD
• Patient is usually old

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COPD

• Altered mental state over time
• Due to CO2 retention
• Barrel shaped chest
• Well developed respiratory muscles
• Long term COPD may cause heart failure

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Spontaneous pneumothorax

• Collapsed portion of lung due to weakness in lung
  tissue
• No apparent cause
• Sudden SOB
• Pleuritic chest pain
• Common in asthmatic/COPD
• Common in tall thin men

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Asthma/allergies

• Reversible spasm of bronchioles
• Excessive mucus production
• Normal inspiration
• Difficult expiration
• Expiratory wheezing common
• A quiet chest is an ominous sign
• Be prepared for respiratory arrest
• Be prepared to use BVM

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Status astmaticus

• An asthma attack that cannot be broken after
  repeated doses of bronchdilators
• Needs aggressive airway management
• Needs rapid transport
• Needs BVM

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Pulmonary embolism

• Embolus something in the circulatory system that
  travels from one place to a distant place and
  lodges there
• Effective inspiration/expiration BUT
• Vessels leading to alveoli are blocked by
• Blood clots
• Often following long bed rest
• Air bubbles
• Often following open neck injuries
• Bone marrow
• Often following a long-bone fracture
• Amniotic fluid
• Often following an explosive delivery

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Pulmonary embolism

• Very often a dangerous complication of a DVT
• Common in pt with varicose veins
• perfusion/ventilation mismatch
• Small emboli may cause no S/S

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Pulmonary embolism

• Common S/S
• Dyspnea
• Pleuritic chest pain
• Hemoptysis
• Cyanosis
• Tachycardia
• Tachypnia
• A large embolus may cause sudden cardiac arrest

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Hyperventilation

• Overbreathing reduces CO2 level excessively
• May be emotional in nature
• May be a sign of MANY serious medical conditions
• DO NOT WITHOLD Oxygen!
• DO NOT HAVE THEM BREATH INTO A BAG!

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Hyperventilation

• Patient may describe
• Numbness/tingling in hands/feet
• Spasms in hands and feet
• Called carpal-pedal syndrome
• If all medical causes have been ruled out IN THE
  HOSPITAL, the condition is called
  Hyperventilation Syndrome

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Treating the dyspneic patient

• Calm approach!
• Call for ALS EARLY!
• Position of comfort
• Almost always sitting upright
• NEVER lie them down
• Especially an APE patient
• High concentration oxygen
• Even for COPD patients
• NRB if rate depth are adequate
• BVM if not

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Treating the dyspneic patient

• Monitor V/S especially resp rate
• Look for signs of sleepiness
• Yawning
• Slowing RR especially in COPD pt.
• ? pt is becoming too tired to breathe
• Respiratory failure
• Breathe for them ? BVM

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Treating the dyspneic patient

• The counting test
• SAMPLE HISTORY
• OPQRST medical assessment Qs
• Onset
• Provocation/Palliation
• Quality (of any pain)
• Radiation
• Severity
• Time
• Interventions
• Also, help them with prescribed inhalers

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Cardiac Emergencies
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Mechanical structure

• Atria
• Ventricles
• One way valves
• Pulmonary arteries
• Pulmonary veins
• Aorta
• Coronary arteries
• Provide O2 and nutrients to the heart muscle
• Myocardium the heart muscle

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Electrical structure

• SA Node
• The dominant pacemaker
• Internodal pathways
• AV Node
• Bundle of HIS
• Bundle branches
• Purkinje Fibers/Network

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Cardiovascular abnormalities

• Atherosclerosis
• Cholesterol/calcium deposit buildup
• Arteriosclerosis
• Hardening of the arteries
• Ischemia
• Temporary interruption of O2 to tissues
• Infarction
• Death of tissue after a period of uncorrected
  ischemia

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Risk factors

• Controllable
• Uncontrollable

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Angina pectoris

• Chest pain
• Supply of O2 does not meet hearts requirement
• Partial blockage
• Spasm? (Prinzmetals Angina)

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Angina -- triggers

• Exercise
• Emotion
• Fear
• Cold
• Large meal
• elimination

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Angina -- presentation

• Crushing/squeezing pain in midchest, under
  sternum (substernal)
• Radiation to jaw, arms, midback
• Nausea
• Dyspnea
• Diaphoresis
• Rarely lasts more than 15 minutes

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Angina-promptly relieved by

• Rest
• Oxygen
• Nitroglycerine
• Dilates blood vessels
• Increases blood flow to heart muscle

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Acute myocardial infarction

• AMI, MI, Heart attack
• May have same S/S as angina, but
• Longer in duration
• Often not relieved with rest, O2, nitro
• May be onset at rest with no triggers
• ? Treat angina as AMI

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Complications of AMI

• Sudden death
• 40 never make it to the hospital
• Arrhythmias
• Most frequent cause of death in early hours
  following AMI
• Congestive Heart Failure (CHF)
• Cardiogenic shock
• At least 40 of the heart is infarcted

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Sad facts

• Unfortunately, the left ventricle is the portion
  of the heart most often infarcted
• The left ventricle is the highest powered portion
  of the heart
• Pumping power of the heart may be severely reduced

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Classical S/S of AMI

• All, some or none of the following
• Sudden onset of weakness, nausea, sweating
• Crushing chest pain does not change with
  breathing
• Pain radiating to jaw, arms, neck
• Sudden arrhythmias causing syncopy
• Acute Pulmonary Edema
• Cardiac Arrest

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Classical S/S of AMI -- 2

• Vital signs -- commonly
• Pulse increased, irregular
• BP Usually normal dropping in cardiogenic shock
• RR Usually normal, elevated in APE
• Feeling of doom
• Looks frightened
• Denial
• ? Diabetics and the elderly ?

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Congestive Heart Failure

• Pathophysiology
• Right sided CHF
• Left sided CHF

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Right sided CHF

• Dependent edema
• Pedal edema, sacral edema
• Enlarged liver
• JVD
• Due to back-pressure from damaged right ventricle
• Chronic condition
• People often live with it for years
• Controlled by
• Medication (Lasix, Digitalis)
• Salt free diet

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Left sided CHF

• APE
• Fluid in the lungs due to back pressure from
  damaged left ventricle
• Patient feels like they are drowning
• Acute condition
• Frequent recurrences
• Often results in death
• Controlled by
• Medication (Lasix, Bumex, Digitalis)
• Salt free diet
• Often a result of long-standing HTN

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APE Calls

• Most of them are due to either
• Poor diet control
• They eat too much sodium filled foods
• Poor compliance with medications
• Lasix is a diuretic
• Annoying side effects

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Cardiogenic Shock

• Heart muscle is so damaged that it can no longer
  pump enough to meet bodily demands
• Very high mortality rates
• Even with the best treatment
• S/S of shock immediately after or within hours or
  days of AMI

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Treating the patient with CP

• Calm reassuring approach
• Cardiac arrest CPR/AED
• High-con Oxygen
• NRB or BVM PRN
• Aspirin 162mg PO
• Call for ALS EARLY!
• For any cardiac/respiratory problem
• Position of comfort
• Usually sitting upright (dyspniac patient)
• NEVER let an APE pt lie down!

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Treating the patient with CP

• Focused history
• OPQRST and in addition
• Previous MI history
• Previous heart problems
• Family history / risk factors
• Monitor vital signs
• Other interventions
• Assist pt with prescribed nitro SL
• If systolic BP gt 120

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