General Discussion

60% of the questions

• priority

• What would you do next?

• What would you do first?

• What are the most appropriate immediate interventions?

Always think-What will overall help my patient the most, prevent them from dying or becoming more critical

Prioritization

!!!!After you have read the entire question, always determine the Differential Diagnosis (What are the different conditions or injuries that are happening)

1. SAFETY!!!!!! (PPE, consider an infectious disease, violence)

2. Treat immediate life threats=STOP any External bleeding

3. Airway (Open/Patent)-Stridor, snoring, tongue, gurgling, vomit, blood, broken teeth, dentures, swelling, secretions

4. Breathing/Oxygenation

5. Circulation-mental status, BP, HR, Skins

6. Pain (No one has ever died from pain)

7. Transport Decision

Normal Adult VS

• HR-60-100 bpm

• RR-12-20

• Spo2-94-100%

Adult Symptomatic Bradycardia

• HR less than 50 bpm w/ symptoms

Unstable (CASH)

• Ischemic CP (Crushing, Pressure, if the CP radiates to left jaw, arm, shoulder)

• ALOC or AMS

• Syncopal episode

• Hypotension

Stable

• No signs of CASH

• Weakness

• Dizziness

• Palpitations

• N/V

• Headache

Paramedic Treatment

• 12 leads

• O2 as needed

• IV

• Atropine 1 mg (except for a 2nd degree type II & 3rd degree block)

• TCP

• OR

• Dopamine 5 mcg/kg/min

• OR

• Epinephrine Infusion 2-10 mcg/min

Tachycardias (Symptomatic)

• V-Tach (w/pulses)

• SVT

• Rapid A-fib w/ RVR

• Rapid A-flutter

!!!!!!CASH GETS THE JOULES!!!!!!

SVT (Stable)-Narrow complex tachycardia

• If unstable, go straight to cardioversion

• Attempt Vagal Maneuvers (Have the pt. bear down or "Diving Reflex-place the pts. face in a bowl of ice or cold water or CSM-Carotid sinus massage)-Rare

• IV line-Left AC

• Adenosine 6 mg RIVP...MR at 12 mg

• Cardioversion

V-Tach w/ pulses (Unstable)

• Immediate cardioversion

V-Tach w/ pulses (Stable)-Wide complex tachycardia

• Amiodarone-150 mg

• OR

• Lidocaine 1 mg/kg

If Amiodarone or Lidocaine does NOT convert the rhythm or you have maxed out the dose=Procainamide

Cardiac Arrest=CAB

• High-quality CPR

• Immediate Defibrillation

If a pt. does have a pulse=ABCs

Example-You have been on scene w/ a 68 female who presented in cardiac arrest, pulseless and apneic. You immediately started CPR, obtained an IV access, and delivered a total of 2 shocks for V-fib on the EKG. En route, you have now achieved ROSC.

1. Obtain Vital Signs

2. Secure an airway-Perform intubation

3. PPV at 10/min-12/min

4. Waveform capnography ETCO2-35-45

5. maintain an Spo2->90%

6. Circulation-maintain a SBP >90 mmHg & a MAP >65 (Fluids or vasopressors)

7. Obtain a 12-lead EKG

8. If comatose or unresponsive, initiate TTM-make them cold-32-37 C

WE CAN'T TREAT WHAT WE DON'T ASSESS!!!

• Smal hosp-30

• medium-30

• large-60 min

percutaneous coronary intervention

• Angioplasty and STENT placement

• ASA, 12 lead, NTG x 1