ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training DOT National Standard EMT-Intermediate/85 Refresher DOT National Standard EMT-Intermediate/85 Refresher Welcome!

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease Allergic reaction Possible overdose Near-drowning ALOC Diabetes Seizures Heat & cold emergencies Behavioral emergencies Suspected communicable disease ■ Provide ventilatory support for a patient ■ Attempt to resuscitate a patient in cardiac arrest ■ Provide care to a patient experiencing cardiovascular compromise ■ Provide post resuscitation care to a cardiac arrest patient

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training MEDICAL EMERGENCIES Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Do not start CPR –Documented pulseless & nonbreathing for more than 15 min by a reliable witness who has observed the pt carefully –Pulseless & nonbreathing w/ signs of prolonged lifelessness (e.g. rigor mortis, lividity) Burns or decapitation Do not start CPR –Documented pulseless & nonbreathing for more than 15 min by a reliable witness who has observed the pt carefully –Pulseless & nonbreathing w/ signs of prolonged lifelessness (e.g. rigor mortis, lividity) Burns or decapitation

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Note: downtime for initiation of CPR is extended from 15min to 30min in certain SPECIAL CASES –Cold water drowning –Hypothermia –Barbiturate OD –Electrocution –Lightning strike Note: downtime for initiation of CPR is extended from 15min to 30min in certain SPECIAL CASES –Cold water drowning –Hypothermia –Barbiturate OD –Electrocution –Lightning strike

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest Adult with AED –If pt is <14yr or shorter than Broselow tape (5feet)- Medical Arrest Without AED or Pediatric Medical Arrest with AED –If pt is a newborn go to protocol - Pediatric - Newborn resuscitation Adult with AED –If pt is <14yr or shorter than Broselow tape (5feet)- Medical Arrest Without AED or Pediatric Medical Arrest with AED –If pt is a newborn go to protocol - Pediatric - Newborn resuscitation

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest 1) Confirm arrest Call for ACLS backup ASAP Check breathing, give 2 breaths if indicated, & check pulse 6 seconds 1) Confirm arrest Call for ACLS backup ASAP Check breathing, give 2 breaths if indicated, & check pulse 6 seconds

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest Assessment –Quickly obtain info (15-30sec) from witnesses to determine whether resuscitation should be initiated & by what means. –As time allows, obtain additional info including preceding events & symptoms, PMH. Assessment –Quickly obtain info (15-30sec) from witnesses to determine whether resuscitation should be initiated & by what means. –As time allows, obtain additional info including preceding events & symptoms, PMH.

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest If downtime of the pt is known to be <4min, then initiate resuscitation w/ the AED If the downtime of the pt is unknown, or is known to be >4min, then initiate resuscitation w/ CPR If downtime of the pt is known to be <4min, then initiate resuscitation w/ the AED If the downtime of the pt is unknown, or is known to be >4min, then initiate resuscitation w/ CPR

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest Apply AED –Turn on AED & follow prompts After initial rhythm analysis, the AED will either recommend a shock or not. Allow the AED to deliver a shock as indicated Apply AED –Turn on AED & follow prompts After initial rhythm analysis, the AED will either recommend a shock or not. Allow the AED to deliver a shock as indicated

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest Airway –Secure airway utilizing OPA/NPA or ALS airway (Combitube or King) Airway –Secure airway utilizing OPA/NPA or ALS airway (Combitube or King)

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest CPR/AED- cycle 1 –1 or 2 rescuer CPR (30:2). Compress 100/min –Ventilate Do not over-inflate Do not ventilate too quickly CPR/AED- cycle 1 –1 or 2 rescuer CPR (30:2). Compress 100/min –Ventilate Do not over-inflate Do not ventilate too quickly

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest CPR/AED- cycle 1 –If AED is already attached to the pt, perform CPR until the AED prompts for the next analysis (approx 2min). Do not check pulse before AED analysis If AED states “shock advised” follow prompts on AED to shock the pt –After shock is done, the AED will state “shock delivered”. Do not check pulse If AED states “no shock advised” then check carotid pulse for 6 seconds –If there’s a pulse>>> CPR/AED- cycle 1 –If AED is already attached to the pt, perform CPR until the AED prompts for the next analysis (approx 2min). Do not check pulse before AED analysis If AED states “shock advised” follow prompts on AED to shock the pt –After shock is done, the AED will state “shock delivered”. Do not check pulse If AED states “no shock advised” then check carotid pulse for 6 seconds –If there’s a pulse>>>

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest If AED is not yet attached to pt, perform 2min of CPR, then attach AED to pt. After initial rhythm analysis, the AED will either recommend a shock or not –If AED states “shock advised” follow prompts on AED to shock the pt. After shock is done, the AED will state “Shock Delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6sec. If pt has a palpable pulse or spontaneous respirations >> If AED is not yet attached to pt, perform 2min of CPR, then attach AED to pt. After initial rhythm analysis, the AED will either recommend a shock or not –If AED states “shock advised” follow prompts on AED to shock the pt. After shock is done, the AED will state “Shock Delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6sec. If pt has a palpable pulse or spontaneous respirations >>

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest CPR/AED - cycle 2 –Perform CPR until AED prompts for the next analysis (approx 2min). Do not check pulse before AED analysis –If AED states “shock advised” follow prompts on AED to shock the pt. After shock is done, the AED will state “Shock Delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6sec. If pt has a palpable pulse or spontaneous respirations >> CPR/AED - cycle 2 –Perform CPR until AED prompts for the next analysis (approx 2min). Do not check pulse before AED analysis –If AED states “shock advised” follow prompts on AED to shock the pt. After shock is done, the AED will state “Shock Delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6sec. If pt has a palpable pulse or spontaneous respirations >>

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest IV –Make 3 attempts If successful, bolus 1-Liter LR/NS (while simultaneously performing resuscitation) If unsuccessful- do NOT attempt to give resuscitation meds w/o IV access –1mg Epi 1:10,000 IVP –Atropine only if pt was NOT shocked in the most recent cycle –Lidocaine administer only if pt WAS shocked in the most recent cycle 100mg IVP over 2 minutes IV –Make 3 attempts If successful, bolus 1-Liter LR/NS (while simultaneously performing resuscitation) If unsuccessful- do NOT attempt to give resuscitation meds w/o IV access –1mg Epi 1:10,000 IVP –Atropine only if pt was NOT shocked in the most recent cycle –Lidocaine administer only if pt WAS shocked in the most recent cycle 100mg IVP over 2 minutes

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest Note –Most AEDs are programmed to analyze heart rhythm in 2min intervals Once IV meds are introduced into the resuscitation, CPR should be performed for 3 min after each round of meds The parkmedic may need override the automatic cycling of the AED Note –Most AEDs are programmed to analyze heart rhythm in 2min intervals Once IV meds are introduced into the resuscitation, CPR should be performed for 3 min after each round of meds The parkmedic may need override the automatic cycling of the AED

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest CPR/AED- cycle 3 –Perform CPR for 3 min after all meds are administered Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP Atropine (administer only if pt WAS NOT shocked in most recent cycle) –Perform CPR for 3 min after all meds are administered CPR/AED- cycle 3 –Perform CPR for 3 min after all meds are administered Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP Atropine (administer only if pt WAS NOT shocked in most recent cycle) –Perform CPR for 3 min after all meds are administered

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest CPR/AED- cycle 4 Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP Atropine (administer only if pt WAS NOT shocked in most recent cycle) –Perform CPR for 3 min after all meds are administered CPR/AED- cycle 4 Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP Atropine (administer only if pt WAS NOT shocked in most recent cycle) –Perform CPR for 3 min after all meds are administered

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest CPR/AED - cycle 5 Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP –Perform CPR for 3 min after all meds are administered CPR/AED - cycle 5 Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP –Perform CPR for 3 min after all meds are administered

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest CPR/AED - cycle 6 Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP –Perform CPR for 3 min after all meds are administered CPR/AED - cycle 6 Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP –Perform CPR for 3 min after all meds are administered

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest CPR/AED - cycle 7 Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP –Perform CPR for 3 min after all meds are administered CPR/AED - cycle 7 Do not check pulse before AED analysis –If AED states “shock advised”- follow prompts. After shock is done, the AED will state “shock delivered”. Do not check pulse –If AED states “no shock advised”, then check carotid pulse for 6 sec »If pt has a palpable pulse or spontaneous respirations>>> »If pt has no palpable pulse or spontaneous respirations- continue resuscitation Epinephrine 1mg 1:10,000 IVP –Perform CPR for 3 min after all meds are administered

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest Reassess –If pt has a palpable pulse or shows signs of life, check pulse q 3 min & provide appropriate ventilatory support –If not previously attempted make 3 attempt at IV placement –If pt was not given Lidocaine during resuscitation Hold for HR<80. IV 100mg slow IVP over 5min (50mg IVP q 30min -max 3mg/kg) Reassess –If pt has a palpable pulse or shows signs of life, check pulse q 3 min & provide appropriate ventilatory support –If not previously attempted make 3 attempt at IV placement –If pt was not given Lidocaine during resuscitation Hold for HR<80. IV 100mg slow IVP over 5min (50mg IVP q 30min -max 3mg/kg)

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest Transport if pt has a palpable pulse or transit time to healthcare facility is <10min Special Cases - transport if pt has a palpable pulse or transit time to healthcare facility <30min If return to spontaneous circulation, keep AED attached to pt in “off”mode. If pt rearrests, turn the AED back to “on” mode & restart CPR/AED cycle Transport if pt has a palpable pulse or transit time to healthcare facility is <10min Special Cases - transport if pt has a palpable pulse or transit time to healthcare facility <30min If return to spontaneous circulation, keep AED attached to pt in “off”mode. If pt rearrests, turn the AED back to “on” mode & restart CPR/AED cycle

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest –Check glucose Cardiac Arrest –Check glucose

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Cardiac Arrest Differential Dx –Reversible causes Cardiogenic shock Cardiac dysrhythmias Hypovolemia Tension pneumothorax Pericardial tamponade Respiratory arrest Allergic reaction Drug/medication/toxic ingestion Hypothermia Hyperthermia Drowning Electrical injury trauma Differential Dx –Reversible causes Cardiogenic shock Cardiac dysrhythmias Hypovolemia Tension pneumothorax Pericardial tamponade Respiratory arrest Allergic reaction Drug/medication/toxic ingestion Hypothermia Hyperthermia Drowning Electrical injury trauma

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx Perspective Pathophysiology Epidemiology PE & Diagnostic Findings S/S Differential considerations Tx

ICEnAXES ICEnAXES EMS & Wilderness Emergency Care Training Questions? References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA References –Marx, John A. ed, Hockberger & Walls, eds et al. Rosen’s Emergency Medicine Concepts and Clinical Practice, 7th edition. Mosby & Elsevier, Philadelphia: PA –Tintinalli, Judith E., ed, Stapczynski & Cline, et al. Tintinalli’s Emergency Medicine A Comprehensive Study Guide, 7th edition. The McGraw-Hill Companies, Inc. New York –Wolfson, Allan B. ed., Hendey, George W.; Ling, Louis J., et al. Clinical Practice of Emergency Medicine, 5th edition. Wolters Kluwer & Lippincott Williams & Wilkings, Philadelphia: PA 2010.