EMS Equipment Review

1
EMS Equipment Review

• March 2015 CE
• Condell Medical Center EMS System CE
• IDPH Site Code 107200E-1215
• Prepared by Sharon Hopkins, RN, BSN, EMT-P

2
Objectives

• Upon successful completion of this module, the
  EMS provider will be able to
• List indications for use of a variety of EMS
  equipment used in the field.
• Manage a group of peers in setting up and
  applying a variety of equipment used in the
  field.
• Evaluate the effectiveness of application of a
  variety of EMS equipment in a practical setting.

3
Objectives contd

• Actively participate in review of selected Region
  X SOPs as related to the topics presented.
• Actively participate in review of the process of
  transmission of 12 lead EKGs using department
  specific equipment.
• Actively participate in reviewing the operation
  of your department monitor/defibrillator, pacing
  capacity, synchronized cardioversion
• and defibrillation at the paramedic level.

4
Objectives contd

• Actively participate in HARE/Saeger traction
  application.
• Successfully complete the post quiz with a score
  of 80 or better.

5
Equipment and Patient Interventions

• There comes responsibility when using equipment
  in the delivery of patient care. You need to
• recognize what the problem is to know what to do
• be able to distinguish what the appropriate
  intervention(s) is/are
• understand how to properly apply and use the
  equipment chosen
• recognize when the intervention is working as
  well as not accomplishing the goal
• know what documentation must be done with each
  piece of equipment used in patient care
• be knowledgeable regarding the cleaning and
  returning to service for each piece of equipment

6
Capnography Background

• A continuous, non-invasive monitoring tool
• Measures level of CO2 at end of exhalation
• Quantitative results provides a number
• Assesses respiratory status thru-out respiratory
  cycle
• Provides current, at the moment, breath-to-breath
  information on patient status
• Results measured as mmHg of CO2
• Normal 35 45 mmHg

7
Capnography Information

• Numeric value provides end tidal (end of breath)
  CO2 level
• Waveform is a picture representation of the CO2
  value exhaled with each breath
• Airway status reflected in
• ETCO2 value (mmHg)
• Waveform picture
• Respiratory rate

8
Definitions

• Ventilation
• Process of breathing eliminating CO2 from body
• Respiration
• Exchange of gasses at alveoli level
• Oxygenation
• Getting O2 to tissues measured by pulse oximetry
• Diffusion
• Process by which gas moves between alveoli and
  pulmonary capillaries (gases move from area of
  high concentration to areas of low concentrations)

9
Capnography Usefulness

• Provides information on how effectively the body
  is
• Producing CO2 (metabolism)
• Transporting CO2 (perfusion)
• Exhaling CO2 (ventilations)
• Goal attain/maintain CO2 levels 35 45 mmHg

10
Capnography Usefulness contd

• Confirms and monitors advanced airway placement
• Indicates effectiveness of chest compressions
• Blood must circulate through lungs to off-load
  CO2 for it to be exhaled
• Levels expected to minimally be gt10mmHg during
  CPR
• Indicates return of spontaneous circulation
  (ROSC)
• Sudden, sustained rise in levels toward 35-45
  mmHg
• Allows early interventions to be started

11
Capnography Usefulness contd

• Monitor asthma COPD conditions and response to
  bronchodilator therapy
• Detect increased respiratory depression and
  hypoventilation
• Tiring accessory muscles
• Neuromuscular disease effect on respiratory
  center
• Change in level of consciousness alcohol/drug
  overdose, head trauma, sedation/analgesia
• Seizure activity /or post ictal period

12
Capnography Waveform

• A-B respiratory baseline
• B-C expiratory upslope
• C-D expiratory plateau
• D end of exhalation
• point of measurement
• D-E inspiratory downslope

13
Capnography Waveforms

• Hypoventilation
• CO2 retained so
  values ?
• Hyperventilation
• CO2 eliminated
  so values ?

14
Capnography Waveforms

• Asthma attack or COPD
• Difficulty exhaling evidenced by slow, gradual
  upslope

15
Capnography Waveforms

• Apnea or loss of
  advanced airway
• - flat line

16
ETCO2 Detector

• End tidal (end of breath) CO2 detector
• Qualitative device
• Indicates presence/absence of detectable CO2
  exhaled via pH sensitive paper
• Does not provide specific measurement of numeric
  value
• Color scale estimates CO2 level
• Able to change as detected levels change
• May take up to 6 breaths to wash enough CO2 out
  for proper measurement

17
ETCO2 contd

• Gastric content or acidic drug contact on pH
  paper can affect accuracy of values detected
• When perfusion decreased
  (shock, arrest) ETCO2 reflects
  change in pulmonary blood flow
  and CO2 level
• Does not reflect ventilation status

18
Altered CO2 Levels

• ? CO2 level
• Shock, cardiac arrest, pulmonary embolism,
  bronchospasm, complete airway obstruction
• ? CO2 level
• Hypoventilation, respiratory depression,
  hyperthermia

19
CO2 Influence on Circulation

• ? CO2 in blood (hypoventilation)
• Cerebral vasodilation ? increase in intracranial
  pressure (ICP) due to increased blood flow to the
  brain
• ? CO2 in blood (hyperventilation)
• Cerebral vasoconstriction ? decrease in fresh
  blood flow to brain decrease in levels of
  adequate oxygen and glucose negatively affect
  function of brain

20
ETCO2 Result Interpretation

• Yellow yes, CO2 is being detected in exhaled
  breath
• Tan poor perfusion or ventilation status
• First evaluate placement of airway device
• Continue to trouble shoot
• Blue or purple no CO2 being detected
• First evaluate placement of airway device
• Continue to trouble shoot

21
Trouble Shooting Advanced Airway Placement
DOPE

• D displacement of tube (i.e. into esophagus)
• Chest rise and fall?
• Gastric sounds?
• Bilateral breath sounds?
• O obstruction
• P pneumothorax
• E equipment failure
• Faulty cuff

22
Esophageal Detector Device - EDD

• A modified bulb syringe
• Simple means of evaluating for missed
  endotracheal intubation
• Squeeze bulb, attach to end of endotracheal tube
• Bulb re-expands tube in trachea
• Bulb does not re-expand or does so slowly
  collapsing sides of esophagus onto tube
  preventing air from filling EDD consider
  esophageal placement

23
EDD contd

• Need to interrupt ventilations to use device
• Evaluate results of technique used with results
  of all other steps of confirmation could be
  extenuating reason why you get false negatives

24
Defibrillators

• Electrical capacitor that stores energy
• Biphasic defibrillators provide waveforms that
  use less DC energy than monophasic machines
• Energy flows in one direction and then reverses
• Therefore, possible decrease in tissue damage
• Survival rates increase if early CPR provided
  with prompt defibrillation attempt as soon as
  possible after collapse

25
Defibrillation

• Early defibrillation critical to survival from
  sudden cardiac arrest
• Most frequent initial rhythm in arrest is VF
• Treatment for VF is defib (defibrillation)
• Probability of successful defibrillation
  diminishes over time
• VF deteriorates to asystole over time
• Check with your vendor to know your biphasic
  devices recommended energy settings

26
Ventricular Fibrillation as Presenting Rhythm

• Best chance of survival in public
• Early activation of EMS
• CPR initiated very soon after collapse
• Early application of AED or other defibrillation
  attempt
• Current passes though fibrillating heart to
  depolarize heart cells to allow them to uniformly
  repolarize
• Allows dominant pacemaker (SA node) to take over
  electrical control
• Goal resume organized electrical activity

27
Influences on Success of Defibrillation

• Time from onset of VF shorter time ? survival
• Condition of myocardium
• Less success in presence of hypoxia, acidosis,
  hypothermia, electrolyte imbalance, drug toxicity
• Pad size
• Larger pads felt to be more effective and cause
  less myocardial damage should not overlap
• Ideal size for adults10-13 cm (4 -5 inches)
• Ideal size for peds 4.5 cm (roughly 3 inches)

28
Influences contd

• Pad / skin interface
• Need to ? the resistance
• Greater the resistance the less energy delivered
  to the heart and the greater the heat production
  at the skin surface
• Pad contact
• Max contact with skin no air bubbles breaking
  contact no pads touching or overlapping
• Avoiding placement of pads over bone
• Bone is poor conductor of electricity

29
Pad PlacementOperator Choice

• Anterior /posterior
• 1 pad over apex of heart, under
  left breast
• 1 pad under left scapula in line
  with anterior pad
• Anterior/anterior (apex)
• Anterior pad on right upper sternum just
  below clavicle
• Apex pad below left nipple in anterior axillary
  line over apex of heart

30
Pad Placement contd

• DO NOT place pads
• Over sternum bone poor conductor of electricity
• Over pacemaker or AICD deflects energy could
  damage the implanted device
• Place at least one inch away from device
• Over topical medication patches deflects energy

31
Defibrillation

• Indications
• VF, pulseless VT
• Contraindications
• Failure to demonstrate one of the above rhythms
• Asystole defibrillation places a patient into
  asystole for the dominant pacemaker to take over
• PEA electrical activity not a problem needs
  mechanical response fixed

32
Defibrillation

• Equipment
• Monitor/defibrillator
• Defibrillating pads
• Example PadPro
• Defibrillation/pacing/cardioversion/monitoring
  electrodes
• Most come with conductive gel already applied in
  center of pad

33
Defibrillation Safety

• CPR is performed just until the defibrillator is
  ready
• Confirm O2 not blowing across patients chest
  wall hold away from the patient when not using
  the BVM
• Physically look all around (nose to toes)
• Clearly yell out all clear
• Deliver energy
• Immediately resume CPR

34
Return of Spontaneous Circulation
ROSC

• After 2 minutes of resumed CPR, evaluate the
  rhythm
• If an organized rhythm is viewed on the monitor,
  THEN check for a pulse
• If no pulse, rhythm is PEA
• Resume CPR
• Adult 1 and 2 man CPR 302
• Infant and child 1 man CPR 302
• Infant and child 2 man CPR 152

35
Indications to Activate Cooling Protocol Post ROSC

• Presumed cardiac arrest
• NOT indicated for respiratory or traumatic arrest
• Remains unconscious and unresponsive
• ROSC present at least 5 minutes
• Systolic B/P gt90 with or without pressor agent
  use (i.e. Dopamine)
• Airway has been secured

36
ROSC Contraindications

• Major head trauma or traumatic arrest
• Recent major surgery within past 14 days
• Systemic infection (i.e. septic shock)
• Coma from other causes
• Active bleeding
• Isolated respiratory arrest
• Hypothermia (34o C/93.2o F) already present

37
Induction of ROSC

• Place ice paks in the axilla, neck and groin
• Areas where blood vessels tend to be superficial
• Place ice pak over IV site
• If patient begins to shiver, contact Medical
  Control
• Anticipate order for Valium to stop the shivering
• Shivering will generate heat and therefore
  increase body temperature

38
Vasopressor - Dopamine

• Stimulates alpha, beta, and dopaminergic
  receptors based on dose provided
• Starting dose 5mcg/kg/min IVPB up to 20
  mcg/kg/min
• Take patients weight and drop last number
• Minus 2 from number left
• Left with rate to run IVPB in drops per minute
• Ex 150 pounds drop 0
• 15 2 13 drops per minute

39
Dopamine contd

• Dopaminergic effects at 2 mcg/kg/min
• Renal vasodilation to improve blood flow to
  kidneys
• Keep kidneys working, the body keeps working
• Beta effects 5 10 mcg/kg/min
• Increases strength of myocardial contraction
  squeeze more blood out of ventricles
• Alpha effects at gt20 mcg/kg/min
• Severe vasoconstriction that diminishes blood
  flow to all tissues

40
AED (Automated External Defibrillator) Function

• AEDs will
• Analyze rhythms
• Deliver a shock if indicated
• Ventricular fibrillation (VF)
• Monomorphic and polymorphic VT if rate and R wave
  morphology exceed preset values
• Will not deliver a synchronized shock
• Can indicate loose electrodes / poor electrode
  contact

41
AED Use in Pediatrics

• Pediatric attenuator used to deliver lower energy
  doses to children (built into cables with peds
  pads)
• 1-8 year old
• Use pediatric pads if available
• No attenuator (peds pads)available, use standard
  AED pads
• lt 1 year old
• Manual defibrillator preferred
• If no manual defibrillator, use peds pads with
  attenuator
• No peds pads, use AED pads available

42
AED Use With CPR

• Do NOT interrupt CPR to apply pads
• Apply pads while CPR in progress
• Do not touch patient during analysis phase
• Can provide compressions during charging phase
• No O2 flow across patient body during
  defibrillation attempt
• Call and look ALL CLEAR prior to each
  defibrillation attempt
• Immediately resume CPR

43
Transition From AED To Defibrillator

• Upon arrival at scene, if AED ready to discharge,
  utilize AED
• Do not interrupt operation of device
• During 2 minutes of CPR, can switch from AED use
  to monitor/defibrillator
• Immediately resume CPR after delivery of each
  defibrillation attempt regardless of equipment
  used

44
Synchronized Cardioversion

• A controlled form of defibrillation using a lower
  energy level that interrupts underlying reentrant
  pathway
• Used with organized rhythms and in presence of a
  pulse
• Monitor interprets QRS cycle and energy delivered
  during R wave
• Less vulnerable area of QRS
• Downslope of T wave is relative refractory area
• Minimal stimulant could generate rhythm into VF

45
Indications Synchronized Cardioversion

• Unstable tachyarrhythmias
• SVT
• Rapid atrial fibrillation or flutter
• Hazard of breaking loose a blood clot in the
  atria and resulting in a stroke
• Ventricular tachycardia
• Note polymorphic VT NOT likely to respond to
  synchronized cardioversion no defined R wave

46
Synchronized Cardioversion Procedure

• Apply pads
• Anterior/anterior or anterior/posterior position
• Sedate if possible
• This is a painful procedure!
• Versed 2 mg IVP/IO repeated every 2 minutes max
  10 mg (desired effect sedation!)
• Consider pain management
• Fentanyl 1 mcg/kg IVP/IN/IO may repeat in 5
  minutes to max of 200 mcg total dose

47
Sync Procedure contd

• Activate sync button
• Verify R wave is being flagged/identified
• Choose energy setting starting at the lowest watt
  setting
• 100j, 200j, 300j, 360j
• Verify O2 not blowing across chest wall
• Look (nose to toes) and call ALL CLEAR
• Press and hold sync buttons until energy
  discharged
• Momentary delay waiting to identify the R wave

48
Sync Procedure contd

• If synchronized cardioversion needs to be
  repeated, need to reset the sync button
• Safety that machine will default to
  defibrillation mode after every discharge of
  energy
• If VF occurs, verify sync mode is off and
  defibrillate patient without delay

49
Transcutaneous Pacemaker - TCP

• Electrical cardiac pacing across the skin
• TCP is a painful non-invasive procedure so
  sedation will most likely be necessary
• Indications
• Symptomatic bradycardia
• Hypotensive
• Hypoperfusing
• Evaluate level of consciousness and B/P for most
  reliable indicators of patient condition/stability

50
TCP Procedure

• Apply pads
• (-) over apex of heart, anterior chest wall
• () mid upper back below left scapula
• Set desired heart rate (80)
• Confirm sensitivity at auto/demand
• Begin mA current at 0
• Turn pacer on

51
TCP Procedure contd

• Slowly increase output until ventricular capture
• Spike followed by widened QRS
• Reassess vital signs and pain level
• Document settings mA and rate
• Reassess need for sedation and analgesia
• Valium 2 mg IVP/IO over 2 minutes repeat every 2
  minutes until max of 10 mg total dose
• Fentanyl 1 mcg/kg IVP/IO/IN can repeat dose in
  5 minutes with max total of 200 mcg

52
Critical Thinking Skill and TCP

• In setting of acute MI, consider contacting
  Medical Control
• May want to decrease heart rate of TCP just
  enough to maintain perfusion
• Want to avoid increasing the work load on the
  heart by automatically selecting 80 as the heart
  rate
• Increasing work load on heart may increase the
  size of the infarction

53
What would you do

• You applied the TCP for a symptomatic bradycardia
• You had a paced rhythm
• You notice the following rhythm strip change
  what is the rhythm and what would you do?
• Reassess patient increase mA consider need for
  CPR

Failure to capture
54
Defibrillation During Pacing Mode

• Check your device for specifics
• When in the pacing mode and the need to
  defibrillate occurs, for some models, you may
  have to turn off the pacing mode
• If pacing must be resumed, reset all levels

55
12 Lead EKGs

• A graphic recording of electrical activity in the
  heart
• Must evaluate the pulse to determine mechanical
  response
• Single lead (i.e. lead II) evaluates cardiac
  rhythms
• 12 lead views can diagnose an acute MI
• Early interpretation of 12 lead EKG ? early
  diagnosing ? early reperfusion restoring blood
  flow to ischemic tissues

56
Acute MI

• Death of portion of heart muscle from prolonged
  deprivation of oxygenated blood
• Hearts demand exceeds supply of oxygen over
  extended period of time
• Often associated with atherosclerosis process
• Location and size of infarct depends on vessel
  involved and site of obstruction
• Left ventricle most common site

57
Evolution of Acute MI

• Ischemia initial lack of oxygen
• ST depression can be reversible
• Injury to myocardial tissue
• ST elevation can be reversible
• Death/infarction
• Necrotic tissue can lead to scar formation
• Irreversible process
• Can leave a positive Q wave marker in leads
  affected

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AMI Process

• Ring of ischemic tissue surrounds infarcted
  myocardium
• Collateral circulation may develop
• Ischemic area often site of arrhythmia development

60
Complications of AMI

• Arrhythmia most common
• VF most lethal
• Most common cause of sudden death within one hour
  of onset of signs and symptoms
• Destruction of myocardial muscle mass can lead to
  CHF due to impairment of pumping capability
• Cardiogenic shock may develop if heart function
  is inefficient and inadequate
• Ventricular aneurysm can develop due to damaged
  wall of heart can rupture causing instant death

61
Patient Assessment

• Pain most common chief complaint
• Lasts more than 30 minutes
• Not relieved by rest or NTG
• Tired and weak most often complaint in elderly,
  long standing diabetic and women
• Determine responses to OPQRST assessment
• Activity at onset, provocation/palliation
  (worsens/improves), quality in their words,
  radiation, severity on 0 -10 scale, time of onset

62
EMS Action

• Apply monitor
• Examine underlying rhythm document rhythm
• Obtain 12 lead EKG
• Evaluate for ST segment elevation
• If elevation, in what group of leads?
• If depressed, look for reciprocal elevation
• Watch for development of arrhythmias

63
Proper Placement EKG Chest Leads
64
Groups of Acute MI by Leads
65
Identifying Groups of ST Elevation
66
Why Aspirin???

• Inhibits platelets from aggregating/collecting at
  site of plaque rupture inside vessel wall
• Decreases morbidity and mortality rate
• Chewed to increase breakdown and absorption time
  of medication
• Patients on daily aspirin already have elevated
  and acceptable blood levels of aspirin dont
  have to supplement a dose if absolutely sure they
  took one today
• Always better to give full dose than to risk
  skipping any dose (just in case of skipped dose)

67
12 Lead EKG Procedure

• Obtain rhythm strip
• Interpret, report and document rhythm
• Obtain 12 lead EKG
• Identified with patient age, sex, department name
  in preparation for transmission
• Review for ST elevation pattern
• Report to Medical Control what you see, then read
  word for word interpretation on 12 lead EKG
  printout

68
12 Lead EKG Documentation

• Interpret the rhythm strip and document on
  patient care run report
• Document presence or absence of ST elevation
• If elevation, report and document in which leads
• Provide copy of rhythm strip and 12 lead EKG to
  ED secretary for placement on patients medical
  record

69
CPAP

• Continuous positive airway pressure
• Effective therapy for acute CHF
  pulmonary edema
• Can avert the need for intubation and mechanical
  ventilation if applied early enough
• Maintains constant pressure within the airway and
  through-out the respiratory cycle
• Keeps alveoli open and expanded
• Increases surface space for diffusion of gases

70
CPAP contd

• Buys time for other therapies
  (i.e. medications) to work
• Precaution
• Too much pressure can
  inhibit ventricular filling
  decreasing cardiac output
• B/P can drop

71
CPAP Indications

• Stable pulmonary edema
• Alert systolic B/P gt90mmHg
• COPD with wheezing
• First contact Medical Control for orders
• For unstable pulmonary edema (altered mental
  status, systolic B/P lt90 mmHg), contact Medical
  Control to discuss use of CPAP
• Reminder all therapies used in pulmonary edema
  have potential to drop the B/P

72
CPAP Contraindications

• Respiratory arrest or apnea
• Pneumothorax or trauma to chest wall
• Tracheostomy present
• Cant get tight fit over trach stoma
• Actively vomiting

73
CPAP Procedure

• Sit patient upright
• Assess and obtain baseline vital signs
• Begin O2 via non-rebreather mask while setting up
  equipment
• Administer first dose NTG
• Used as venodilator to decrease blood return to
  heart (decreases pre-load)

74
CPAP Flow Safe II Procedure

• Assemble CPAP Flow Safe II
• Attach proximal end of O2 tubing with manometer
  to port in mask
• Attach distal end of tubing to O2 source
• Secure face mask snugly to patients face using
  head harness
• Adjust O2 flow 13-14 lpm for 10 cm H2O
• Continue administration of medications

75
CPAP Procedure contd

• Lasix 40 mg IVP (80mg if on med at home) as a
  diuretic
• If systolic B/P remains gt90 mmHg
• Morphine 2 mg IVP slowly over 2 minutes
• May repeat 2 mg every 2 minutes as needed to max
  of 10 mg
• Used to decrease anxiety and for benefit of
  vasodilation
• If patient shows deterioration during CPAP
  treatment, remove CPAP, consider intubation,
  inform Medical Control

76
CPAP Tidbits

• Be prepared to coach patient through first few
  minutes of CPAP use until positive effects begin
• Patient is already frightened
• Patient may feel suffocated with the mask on
• Exhaling against the resistance is tough at first

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77
HARE and Saeger Traction

• Indicated for isolated mid-femur fractures
• Reduces muscle spasm and therefore pain level
• Reduces risk of bones overriding
• Contraindications
• Open fracture
• Do not want to draw contamination into the wound
• Hip, knee, or pelvic fractures
• Increased risk of nervous or vascular
  complications

78
Preparing for Traction Application

• Assess motor/sensory/circulation before and after
  splinting
• Can you move this/can you feel that?
• Mark pulses once found easier to find the site
  on reassessment
• Compare to uninjured side
• Apply manual traction until mechanical traction
  in place

79
HARE Application

• Measure and adjust splint
• Support distal end of splint on backboard
• Apply distal ankle hitch while maintaining
  manual traction
• Position traction under injured extremity
• Secure proximal end to groin area
• Apply hook to ankle hitch
• Replace manual traction with mechanical traction

80
HARE Traction

• Adjust straps avoiding over the knee and over the
  injured site

81
Saeger Traction Application

• Support leg and maintain gentle traction
• Use uninjured leg to measure and adjust splint
  length
• Place splint inside injure leg padded bar snug
  against pelvis in groin (watch pressure areas!!!)
• Attach strap to thigh
• Attach padded hitch to foot and ankle
• Extend splint until correct tension obtained
• Apply elastic straps to secure leg to splint

82
Saeger Splint

• Do not place straps over fracture
  site
• Release manual
  traction
• Reassess distal pulse,
  motor, and sensory

83
Pain Control With Use of Traction

• Fentanyl 1 mcg/kg IVP/IN/IO
• May repeat same dose in 5 minutes
• Max total dose of 200 mcg
• As a CNS depressant, watch the respiratory status
• If respiratory depression occurs, begin to
  support ventilations via BVM
• 1 Breath every 5 6 seconds
• Document 10 -12 breaths per minute assisted
• Narcan 2 mg IVP/IN/IO can be used to reverse
  respiratory depression due to opioid use

84
Cleaning of Traction Splints

• Rinse off gross contaminant
• Wet down all surfaces with Cavicide wipes
• Let device air dry
• Confirm all straps are accounted for and
  repackage device in preparation for next patient

85
Combat Application Tourniquet - CAT

• Indications
• Uncontrollable hemorrhage when
  usual means have failed
• Contraindications
• Non-compressable site
• Equipment
• Tourniquet with attached rod

86
CAT - Procedure

• Apply tourniquet proximal to bleeding site as
  distal as possible preferably over bare skin
• Pull band very tight and securely fasten band
  back on itself
• Twist rod until bright red bleeding has stopped
• Or until distal pulses are eliminated
• Place rod inside clip locking into place
• Secure straps over clip holding rod

87
CAT Potential Problems

• Inability to control bleeding
• Continue with direct pressure
• Prepare to apply a second CAT
• Apply QuikClot dressing if available
• Must be applied directly over wound site for
  impregnated material to be effective

88
CAT Documentation Pearls

• Reason CAT was applied
• Time and site of CAT application
• Results post intervention
• Consideration of administration of pain
  medication
• Fentanyl 1 mcg/kg IVP/IN/IO
• May repeat in 5 minutes, same dose
• Max 200 mcg total dosing

89
Midazolam - Versed?

• Potent, rapid onset, short acting benzodiazepine
• Onset 3-5 minutes
• Duration 20-30 minutes
• Used as sedative and hypnotic
• Has amnesic properties and reduces anxiety
• Amnesia of recent past (antegrade) useful to
  inhibit unpleasant reminders of procedures
• Low toxicity and high rate of effectiveness

90
Indications for Versed? Per Region X SOPs

• Sedation prior to synchronized cardioversion
• Useful to maintain sedation post drug assisted
  intubation procedure
• Suppresses seizure activity
• IN route allows safer delivery method
• Decreases severe anxiety and apprehension

91
Precautions With Versed?

• Crosses placental barrier could cause
  respiratory depression in newly born infant
• Elderly more sensitive to effects metabolize med
  more slowly
• Toxicity increases when mixed with CNS
  depressants (alcohol, opioids like Fentanyl,
  tricyclic antidepressants)
• Toxicity may be higher in patients with COPD

92
Side Effects of Versed?

• Respiratory depression
• Drowsiness
• Hypotension
• When administering, have a BVM readily available
• Be prepared to assist respirations
• 1 breath every 5 6 seconds
• Document 10 12 breaths per minute assisted

93
Fentanyl

• Synthetic opiate analgesic for pain control
• Shorter acting than morphine
• Onset immediate when administered IVP
• Peak effect 3 5 minutes
• Lasts 30 60 minutes
• Does not affect blood pressure like Morphine does

94
Dosing For Fentanyl per Region X SOPs

• Adult
• 1 mcg/kg IN/IVP/IO
• May repeat same dose in 5 minutes
• Max total dose 200 mcg
• Pediatrics
• 0.5 mcg/kg IVP/IN/IO
• May repeat same dose in 5 minutes
• Max total dose 200 mcg

95
Precautions With Fentanyl

• Crosses the placental barrier could cause
  respiratory depression in newly born infant
• Monitor respiratory rate, SpO2 levels, and level
  of consciousness
• Have BVM available to counteract potential
  respiratory depression
• 1 breath every 5 6 seconds
• Document 10 12 respirations per minute

96
Cleaning of Equipment After Every
Patient Use

• In general, each piece of equipment in contact
  with a patient MUST be cleaned between each
  patient use
• Gross contaminant must be removed
• Surfaces need to remain wet and allowed to air
  dry
• All cables need to be wiped down (i.e. EKG, B/P,
  pulse ox)
• Cables drag across contaminated surfaces A LOT!!!
• B/P cuffs need to be wiped down
• Pulse ox sensors need to be cleaned following
  manufacturer recommendations

97
Department Review of Equipment

• Review set up of capnography monitoring
• Review operation of monitor/defibrillator for
  defibrillation, synchronized cardioversion, and
  TCP
• Review procedures for transmission of 12 lead EKG
  to receiving hospital
• In teams, apply the HARE or Saeger traction
  device to a peer

98
Bibliography

• Bledsoe, B., Porter, R., Cherry, R. Paramedic
  Care Principles Practices, 4th edition. Brady.
  2013.
• Campbell, J., International Trauma Life Support
  for Emergency Care Providers. 7th Edition.
  Pearson. 2012.
• McDonald, J. ALS Skills Review. AAOS. Jones and
  Bartlett. 2009.
• Mistovich, J., Karren, K. Prehospital Emergency
  Care 9th Edition. Brady. 2010.
• Pediatric Education for Prehospital Professionals
  3rd Edition. American Academy of Pediatrics.
  2014.
• Region X SOPs IDPH Approved January 6, 2012.
• www.MARescue.com