1. Beausoleil, Muskoka & Rama CME 2010

2. Agenda Didactic: –STEMI update –TOR –King LT –Anaphylaxis Skills –Neonatal Resuscitation –Cardiac arrest & KING LT –Breath sounds –IM injection –IV start, fluid and dextrose administration Scenarios KAT

3. General Housekeeping Did your name, address, telephone, cell phone or email change since the last CME? If so please fill out a medic info sheet! THANK YOU

4. Auditing Housekeeping Please ensure the use of –010 Vital signs code. Document Vital signs pre and post each medication administration on the ACR, not as a group at the bottom of the ACR Do not use a procedure code (i.e. 615 NTG) when you are ruling out NTG administration. Use 030 ALS assessment

5. What do I attach to the ACR? From the LP15 printouts: Vital sign log ECG with O 2 Sat waveform (Plethysmograph) All 12 Lead ECG’s with patients name recorded on each ECG.

6. TIME = Cardiac Muscle

7. Likely to be older (74 v 67)Likely to be older (74 v 67) Women (49% v 38%)Women (49% v 38%) Diabetic (33% v 25%)Diabetic (33% v 25%) Prior heart failure (26% v 12%)Prior heart failure (26% v 12%) Longer delay to assessment (8% v 5%)Longer delay to assessment (8% v 5%) Less likely to be diagnosed (22% v 50%)Less likely to be diagnosed (22% v 50%) Less likely to receive treatment (25% v 74%)Less likely to receive treatment (25% v 74%) Most likely to die (23% v 9%)Most likely to die (23% v 9%) Patient Presentation 33% of patients with confirmed MI present with S & S other than chest discomfort. This group compared with those that present with chest discomfort are:

8. Pre-Hospital 12 Lead Perform a history and physical exam Patients ≥40 kg with signs and symptoms of cardiac ischemia you must acquire a 12 lead ECG –Software will interpret findings STEMI positive ECG LP 12 *****Acute MI Suspected****** LP 15*** Meets ST Elevation MI Criteria**** STEMI negative ECG All other statements

9. 12 Lead ECG acquisition Must be performed on all patients presenting with signs and symptoms of cardiac ischemia Must input age and sex

10. 12 Lead ECG acquisition 3 ECGs will be done on these patients: –First on scene as early as possible –Second prior to departure –Third upon arrival at medical facility

11. TOR When to call the BHP for termination of resuscitation?

12. Medical TOR (page 42) Age > 18 years old No ALS procedures Cardiac in nature 3 No shocks on scene Witnessed by EMS or Fire? Any shocks delivered? Was there a ROSC? YES or uncertain = continue resuscitation & transport NO = continue resuscitation and PATCH to BHP for medical TOR & continue transport.

13. Trauma TOR (page 23 & 24) Trauma TOR Age > 16 years old Blunt trauma = Big pads –Shock delivered, transport –No shock, No pulse, HR>0, transport –No shock, No pulse, No HR, patch for trauma TOR Penetrating trauma = Petite pads (Electrodes) –HR >0, ED <20 minutes, transport –HR >0, ED >20 minutes, patch for trauma TOR –HR 0, patch for trauma TOR Trauma patients that have received a TOR after a patch are to be left on the scene.

14. King LT Click on video to start

15. King LT versus LMA KING LT Size 3,4,5 Inflation volume Esophageal Blind insertion 2 cuffs –Distal cuff inflates in the esophagus –Proximal cuff inflates at the base of the tongue LMA Size Inflation volume Supraglottic Visualized insertion Single cuff

16. Neonatal Resuscitation

17. NRP (page 32) Prepare equipment Team approach 30 second blocks

18. What does meconium look like?

19. ANAPHYLAXIS REVIEW Continuing Education

20. Outline Definition Incidence Pathophysiology Signs and Symptoms Diagnosis Indication for Epinephrine SQ/IM Case Presentation

21. Definition of Anaphylaxis A systemic reaction to a protein (antigen) Caused by the release of immunoglobulin E (IgE) IgE acts on mast cells and basophils Mast cells and basophils release chemical mediators; including histamine Histamine and other inflammatory agents act on smooth muscle, connective tissue and mucous glands

22. Picture http://www.world-drugs.net/generic_cetirizine_clip_image002.jpg

23. Incidence Difficult to get true numbers Many reactions are mild and not reported or misdiagnosed Up to 15% of population may be at risk

24. Pathophysiology Anaphylactic and Anaphylactoid reactions occur due to the systemic release of chemical mediators from mast cells and basophils Histamine is the primary mediator involved in urticaria, bronchospasm and anaphylactic shock

25. Pathophysiology Histamine binds to H 1 and H 2 receptors Binding of histamine to H 1 and H 2 receptors mediates pruritis, rhinorrhea, tachycardia, bronchospasm, hypotension, flushing and headache

26. Signs and Symptoms Skin: Itching, Urticaria Angioedema, flushing Respiratory: Hoarseness, stridor Dyspnea, wheezing, rhinitis GI: Nausea, vomiting Cramping, diarrhea

27. Pictures: http://healthsymptomspictures.com/wp-content/uploads/2009/11/anaphylaxis.jpg

28. Signs and Symptoms Cardiovascular: Dizziness,Chest Pain (uncommon) Tachycardia, hypotension Neurologic: Headache, decreased LOA (due to hypotension +/- hypoxia), seizures-uncommon

29. Signs and Symptoms Skin findings are the most common BUT up to 20% of patients do not have hives or other skin symptoms Respiratory symptoms are the second most common deaths result from severe bronchospasm and airway and laryngeal edema

30. Diagnosis Diagnosis is made clinically: History of exposure to possible allergen followed by development of symptoms consistent with anaphylaxis Development of urticaria, laryngeal edema, bronchospasm and/or hypotension with other signs associated with anaphylaxis Rebound reactions can occur up to 24 hours later

31. Treatment ? First line is Epinephrine SQ/IM Other treatments: antihistamines, corticosteroids, bronchodilators, IV fluids without administration of epinephrine fail to prevent or relieve severe anaphylaxis Epinephrine in the setting of anaphylaxis has greater benefit than risk

32. What are the Indications for Epi SQ/IM Confirmed or suspected exposure to a probable allergen Signs and symptoms of a severe anaphylactic reaction –Involvement of more than one body system –E.g.: Urticaria and nausea –E.g.: shortness of breath with wheezing and facial edema –OR any airway symptoms

33. Case Presentation 8 year old female began to have shortness of breath with wheezing and tightness in her throat while running a race at school EMS is called 20 minutes later because the patient’s symptoms have not subsided and the patient now has a hoarse voice Has had a similar reaction in the past but there was no specific allergen found Pulse: 132, Resp: 24, BP: 80/62 Diagnosis? Treatment?

34. QUESTIONS

35. Jeopardy