General Discussion

Clinical Judgement Scenarios

• Worth 38-42% of the exam

• 4-7

Clinical judgement questions test your ability to:

• Choose the NEXT BEST step, NOT just the correct one

• Understanding the pathophysiology of the conditions, while looking at the patient's history and risk factors

• Prioritizing interventions correctly

• It does NOT reward MEMORIZATION!!!!!!

For example, you may know how to administer oxygen, but clinical judgement determines....

• When its needed

• Why it's needed

• What comes first before it

• Do not look at the question in the scenario first!!!

   

• Read the dispatch notes, the on scene note, or the post scene information before reading the actual question, and start to breakdown and interpret the info

Always pay attention to the following:

• Who you are working with (Another Medic, AEMT, EMT)-delegation, additional resources

• The time of day (Night, Afternoon, Morning)

• The Weather & Road Conditions

• Patient's allergies

• The age, history, risk factors and home medications of the patient

• The ETA in time/miles or minutes of your destination hospitals

• If the ETA is ever >30 min-Consider a helicopter (Medical or Trauma)-Weather permitting (Raining, Snowing, Storming)

Helicopter Ops

• LZ needs to be 100 ft X 100 ft

• No overhead obstructions (powerlines, trees, branches)

• Flat ground, minimal to no angles or slopes

• No debris, sand

• Headlights on, each corner, facing inward

• NEVER approach the helicopter from the rear

• Only approach upon making eye contact w/ the pilot and his direction

• Eye protection, ear protection, helmet

• No loose sheets or objects on the gurney

EXTREMELY IMPORTANT!!!! ⚠️⚠️⚠️

• If you are going to do an intervention or give a medication, make for DAMN SURE there are NO contraindications or allergies

DON'T GET LOST IN THE SCENARIO!!!!

• ALWAYS keep track of what you have done throughout the scenario and pay attention if the patient is improving or getting worse. Use the whiteboard provided

• Always check for additional information from 1 part of the scenario to the next part (They DO add information)

• Do NOT re-invent the wheel (If they have done something or are doing something in the question, and it is NOT working, don't turn around and choose the same or similar intervention

• Asthma patient, asthma attack, they state they took their MDI of albuterol and a nebulizer PTA w/ no relief

• Know your treatment algorithms and apply them to the scenario!!!

• Remember, start low and go slow-BLS to ALS & Least invasive to most invasive

EKGs

Think of the leads as cameras at your home

Limb leads

• Leads I, II, III

• + always looks to - (Negative)

Precordial Leads

• Leads V1-V6

Augmented Leads

• aVF

• aVL (augmented vector left)

• aVR

Septal Wall (Middle)

• V1 & V2

Anterior Wall (Front)

• V3 & V4

Lateral Wall (Side)

• Leads I, aVL, V5, V6

Inferior Wall (Bottom right)

• Leads II, III, aVF

ACLS

Stable vs Unstable

CASH

• Ischemic CP

• AMS

• Syncope/SOB w/ severe hypoxia

• Hypotension

Bradycardia (less than 50/min)

• Symptomatic

Paramedic Treatment

• ABCs & O2 as needed

• 12 lead EKG

• IV

• Atropine 1 mg (Except for a 2nd degree type II or 3rd degree blocks)

• TCP

• OR

• Dopamine (5 mcg/kg/min-20)

• OR

• Epinephrine infusion (2-10 mcg/min)

_______________________________________________________

Tachycardias

Narrow complex tachycardia=SVT

Wide complex tachycardia=V-Tach

SVT

• ALWAYS REGULAR

• Narrow QRS (Less than .12)

• No P-waves

• >150

Stable SVT (No signs of CASH)

Paramedic Treatment

• ABCs & O2 as needed

• 12 lead EKG

• IV (LAC)

• Vagal maneuvers (1. Valsalva or Bearing Down 2. Diving Reflex (place their face in a bowl of cold water or ice)

• Adenosine 6 mg IVP

• MR at 12 mg once

• If you have maxed out adenosine and they remain stable, consider calcium channel blocker (Cardizem) or Beta Blocker (metoprolol)

You have a 52 female c/o weakness, dizziness and nausea. VS-BP-118/72, HR-160 bpm, RR-22, Spo2-96%, You have SVT on the monitor. You have attempted vagal maneuvers w/o success, and have administered 6 mg and 12 mg of adenosine w/ no change

Unstable SVT

• Immediate Cardioversion at 100 J

________________________________________

GI Tract

• Goes from the GUMS to the BUM

Upper GI Tract

• Oropharynx

• Epiglottis

• Esophagus

• Stomach

• Duodenum

Lower GI Tract

• Other 2 parts of the small intestine (Jejunum, Ileum)

• Entire Large Intestine (Colon)

• Rectum

• Anus

Upper GI Bleeds

Esophageal Bleed

• Esophageal Varices (varicose vein-swollen vein)

• Mallory-Weiss Tear (tear in the esophagus)-Pregnancy, forceful vomiting, alcoholics

• Boerhaave Syndrome-A complete rupture of the lower esophagus

Diverticulum

• Inner lining of the colon (Large intestine)

Petechiae (rash)

• Small purple dots on the skin=indicate a clotting issue=bleeding

Purpura

• Large purple dots on the skin

Commotio Cordis

• Most often seen in young males between 12-30 yrs

• caused by a blunt impact to the chest

• R-on-T Phenomenon

• Puts the pt. into immediate V-Fib or V-tach

Pulseless/Apneic=CAB

If there is a pulse=ABC

ROSC (Return of Spontaneous Circulation)

• Obtain Vital Signs

• AIRWAY-Secure an airway and intubate

• BREATHING-Attach waveform capnography=ETCO2-35-45. ventilate at 10-12/min, Maintain Spo2-90-98%

• CIRCULATION-maintain a MAP >65 (Fluids or Vasopressors)

• Obtain a 12-lead EKG

• If they are unresponsive=Initiate TTM (targeted temp management)-Purposely make them Hypothermic (32-38 C)

• Maintain BGL=70-180

35 C

35 x 2=70 + 25-95 F

Celsius to Fahrenheit

1. Double the Celsius

2. Add 25

• Stimulant OD

• Aspirin Toxicity

• Serotonin Syndrome

• TCA OD

• Cholinergic=Organophosphates