EMR CLASS

Scene Survey

HEMP-RBC

Classification(s) of acetaminophen

Analgesic: Acetaminophen is a pain relieving medication.

Antipyretic: Acetaminophen can also lower fever. However, it is not within the licensed scope of practice for EMRs in British Columbia to administer acetaminophen for its antipyretic effect!

Mechanism of action of acetaminophen

inhibits the action of an enzyme called prostaglandin synthetase. This enzyme functions in the transmission of pain signals through sensory nerves; inhibiting it's action reduces the sensation of pain.

Indications of acetaminophen

primarily indicated for mild to moderate pain. However, it can be considered as part of an overall pain management strategy for people experiencing severe pain as well.

Contraindications of acetaminophen

check for hypersensitivity or allergy before administering.

Acetaminophen is metabolized through the liver and can cause significant liver damage if taken at high doses, or by vulnerable patients. This accounts for the remaining contraindications:

- Severe hepatic impairment or severe active liver disease

-if acetaminophen overdose is suspected, indicated by symptoms such as nausea, vomiting, or right upper quadrant pain along with a suspected or known history of taking acetaminophen

- if acetaminophen has been given within the past 4 hours (from all sources), or if total acetaminophen intake within the last 24 hours exceeds the daily maximums 4000mg

Cautions for acetaminophen

Heavy alcohol use, Chronic malnutrition, Hypovolemia

Adverse effects of acetaminophen

Rashes and hives (rare)

Dosage of acetaminophen

Adults can be administered 500-1000 mg of acetaminophen. Acetaminophen is administered orally (PO) in a 500 mg pill, so 1-2 pills. In most cases, 1000 mg is appropriate - consider the lower dose for very mild pain, or for patients who have one of the medication cautions listed above. Patients should not take more than 4000 mg of acetaminophen in a 24 hour period. Always verify whether or not the patient has taken any acetaminophen in the last 24 hours from any source - many over the counter medications contain acetaminophen, and you sometimes have to do a bit of detective work to figure this out.

Pharmacokinetics of acetaminophen

Onset: 30 minutes Peak: 1-3 hours Duration: 4 hours

Effect of using acetaminophen and ibuprofen

Acetaminophen may be used concurrently with ibuprofen for analgesia. Increasing the effect of both

Classifications of ibuprofen

Analgesic: Ibuprofen is a pain relieving medication.

Antipyretic: Ibuprofen can also lower fever.

Nonsteroidal anti-inflammatory (NSAID): Inflammation is a normal part of the body's response to injury. However, inflammation can have unwanted or unpleasant effects, such as pain and swelling. Anti-inflammatory medications reduce this effect. only licensed to administer ibuprofen to treat a patient's pain - not for it's antipyretic or anti-inflammatory effects.

Mechanism of action of ibuprofen

directly inhibits prostaglandin synthesis, or creation. Similar to acetaminophen, this reduces transmission of pain signals through sensory nerves; the slightly different way in which it does this is responsible for its anti-inflammatory effect.

Indications of ibuprofen

Ibuprofen is primarily indicated for mild to moderate pain. However, it can be considered as part of an overall pain management strategy for people experiencing severe pain as well.

Contraindication of iburprofen

check for ibuprofen hypersensitivity or allergy before administering.also contraindicated if the patient has a hypersensitivity to other NSAID drugs (ex. naproxen).

Ibuprofen can cause ulceration in the gastrointestinal tract. It can also cross the placental barrier, and affect the fetus. These are the reasons for its other contraindications:

Active GI hemorrhage or ulcers.

Pregnancy

Cautions of ibuprofen

Any history of significant renal, cardiovascular or gastrointestinal disease.

Adverse effects of ibuprofen

Gastrointestinal upset, ranging from abdominal discomfort to gastric ulceration, bleeding, and perforation.

Dosage of ibuprofen

Adults can be administered 200-400 mg of ibuprofen. Ibuprofen is administered orally (PO) in a 200 mg pill, so 1-2 pills. In most cases, 400 mg is appropriate - consider the lower dose for very mild pain, or for patients who have one of the cautions listed above. Patients should not take more than 1200 mg of ibuprofen in a 24 hour period.

Pharmacokinetics of ibuprofen

Onset: 30-60 minutes, Peak: 1-2 hours, Duration: 4-6 hours

What is a key difference between ibuprofen and acetaminophen in terms of classification?

Ibuprofen is also a nonsteroidal anti-inflammatory (NSAID); acetaminophen is not

What is the primary action of naloxone (Narcan)?

It reverses opioid effects by blocking opioid receptors

What position is best for a patient who is conscious and agitated, with laboured breathing at 24 Breaths per minute

seated or tripod

What position is best for a patient who is pain responsive with no injuries

recovery position to protect airway

What position is best for a patient who is unresponsive with a breathing rate of 4/min

supine to use BVM.

What is the most appropriate initial maneuver to open an airway on an unresponsive patient?

JAW THRUST

Which airway adjunct is most appropriate for a pain responsive or unresponsive patient with a gag reflex and inadequate airway maintenance?

Nasopharyngeal airway (NPA)

Most likely cause of a tachypnea breathing pattern

early respiratory distress or fever

Tachypnea

rapid, shallow breathing, typically exceeding 20 breaths per minute in adults at rest. It is a symptom, not a disease, often indicating underlying conditions such as asthma, pneumonia, heart failure, or anxiety

Most likely cause of a cheyne stokes breathing pattern

brain injury or stroke

Cheyne stokes breathing

a distinct, abnormal pattern of breathing characterized by a repeating cycle of progressively deeper—and sometimes faster—breaths, followed by a gradual decrease in breathing, and ending in a temporary pause called apnea, frequently associated with severe heart failure or neurological damage, and is also common in the final days of life

Most likely cause of a kussmaul respirations breathing pattern

diabetic ketoacidosis (hyperglycemic emergency)

Kussmaul respirations

a deep, rapid, and labored breathing pattern that acts as the body's compensatory mechanism for severe metabolic acidosis.

Most likely cause of a bradypnea breathing pattern

narcotic overdose

Bradypnea

abnormally slow breathing rate. For adults, this means taking fewer than 12 breaths per minute at rest.

Stridor

high pitched sound from upper airway obstruction

Why is it important not to ventilate a patient too aggressively with a BVM?

It can increase intrathoracic pressure, preventing cardiac output, and increase the risk of gastric inflation, increasing the risk of vomiting

What respiratory pattern may indicate serious brain injury or brainstem dysfunction?

Cheyne-Stokes breathing

signs of increased work of breathing?

nasal flaring (especially in children), tripod positioning, retractions of the intercoastal muscles, use of accessory muscles of respiration (at base of neck and top of clavicals)

What is the recommended action for a patient in mild respiratory distress who is speaking in full sentences?

Provide high flow oxygen with a non-rebreather mask and monitor for deterioration

Best emergency treatment for a breathing rate of 40, shallow and laboured, anxious and cyanotic patient

assist ventilations with a BVM in a seated position after carefully coaching the patient and getting their consent and cooperation

Best position for respiratory distress with coarse crackles or silent lungs on auscultation

seated position

Best treatment for unconscious not breathing patient found with an empty bottle of tramadol

assist ventilations with a BVM attached to high flow O2; administer naloxone (to reverse suspected opioid poisoning)

How to stop snoring respirations

jaw thrust to lift tongue away

How to stop gurgling in an unconscious patient

suction or roll fluid out of airway

What medication to treat respiratory distress with inspiratory wheezes on auscultation and difficulty exhaling

Ventolin/salbutamol

Typical characteristic of left sided congestive heart failure

fluid overload leading to pulmonary edema

Typical characteristic of asthma

reversible bronchospasm usually triggered by irritants

Typical characteristic of COPD

progressive airflow limitation, often smoker related

Typical characteristic of Acute respiratory distress syndrome

severe inflammation and non cardiogenic pulmonary edema

Air hunger vs laboured breathing

difficulty with oxygenation (air hunger) vs ventilation issues. Air huger is short of breath with no difficulty breathing, while laboured is difficult breathing.

Respiratory distress treatment priorities in the primary survey

Position them in a seated position, if possible, to make breathing easier. If required, assist their breathing with a BVM attached to high flow oxygen. If you are not using a BVM, administer high flow oxygen using a non-rebreather mask. Administer or assist with medications if indicated (some of these patients will benefit from salbutamol, or Ventolin; others will not). Auscultate the patient's breath sounds, and repeat auscultation with each set of vitals. Initiate rapid transport to a higher level of care within 10 minutes of arriving on scene

LOC-ABC for a respiratory distress

LOC - ARE THEY CONSCIOUS? Move them to a seated position. Is BREATHING ineffective? Assist with BVM. either way if in respiratory distress apply high flow oxygen with a non rebreather (or through a BVM if needed)

RBS for a respiratory distress

Expose and examine the chest for increased work of breathing.

Examine the ankles and lower legs for pitting edema that suggests congestive heart failure (CHF).

SOAP for a respiratory distress

Check the oxygen tubing for kinks and the reservoir bag on the NRB or BVM to make sure it's filling properly; check the flow rate settings on the oxygen tank to make sure they correct. 2. Check the patient's pulse oximetry (SpO2) 3. Consider an airway adjunct if the patient is unconscious.

Decision stage of a respiratory distress after primary assessment

1. request stretcher,

2. 2. auscultate lung sounds.

3. 3. If indicated (you hear wheezes consistent with bronchospasm) get a set of vitals and administer salbutamol (Ventolin).

4. 4. Position your patient on the stretcher in Fowler's position (if they are conscious) and move them to the ambulance for transport.

5. 5. Reassess their LOC and ABCs in the ambulance, and adjust your treatments if necessary.

Ongoing care of a respiratory distress patient on route to hospital in RTC

1.Perform a vitals check every five minutes, paying special attention to level of consciousness, breathing rate and work of breathing, and SpO2. Adjust your treatments if necessary based on what you find.

2. Auscultate your patient with each vitals check, making note of any changes that you find.

3. Re-administer medications if permitted and still indicated.

How to administer BVM on a conscious person

keep them in a SEATED position. This requires coaching, and your patient's consent and cooperation to do successfully.

How to administer BVM on an unconscious person

must be in a SUPINE position. Start with a 2-person BVM technique, then move to a 1-person technique if necessary. Only move on once you are sure that breathing is being supported correctly.

What classification(s) of medication is salbutamol/ventolin and its role

a bronchodilator, used to treat bronchospasm, usually from an asthma attack or an exacerbation of COPD.

also a Sympathomimetic: Stimulates the sympathetic nervous system (increases heart rate, blood pressure, breathing rate and alertness).

Mechanism of action for salbutamol/ventolin

Selective β2 (beta 2 cell receptors, mostly in the lungs and blood vessels) stimulation resulting in bronchodilation and some degree of vasodilation Some β1 (Beta 1 cell receptors, mostly in the heart) effects with repeated doses (increasing heart rate and contractile force)

Indications of salbutamol/ventolin

indicated for treatment of bronchospasm associated with asthma, bronchitis, or emphysema.also indicated to treat bronchospasm and wheezing secondary to other causes, such as anaphylaxis

Contraindications of salbutamol/ventolin

Known hypersensitivity or allergy to Salbutamol

Hemodynamically uncontrolled tachyarrhythmias >120 bpm

Cautions of salbutamol/ventolin

Coronary disease, COPD patients with degenerative heart disease, Diabetes

Side effects of salbutamol/ventolin

Restlessness, weakness, vertigo, apprehensiveness, Nausea and vomiting, Tachycardia or other dysrhythmias, Paradoxical worsening of respiratory distress, Cough, Sweating, pallor, flushing, Tremors

Routes for salbutamol/ventolin doses

inhaled medication that can be administered with a Metered Dose Inhaler (MDI, puffer) or nebulized

Dosage for nebulized salbutamol/ventolin

Adult Dose: 5 mg; repeat as required Pediatric Dose: Age >1 year: 5 mg; repeat as required. Age < 1 year: 2.5 mg; repeat as required.

Dosage for metered dose inhalers (MDI, PUFFER) for salbutamol/ventolin

Adult Dose: 4 x 100 mcg per course; repeat as required Pediatric Dose: < 10 kg: not indicated. 10-20 kg: 5 x 100 mcg per course; may repeat up to 3 times. > 20 kg: 10 x 100 mcg per course; may repeat up to 3 times

Pharmacokinetics of salbutamol

Onset of Action: 5 minutes. Peak Action: 60-90 minutes. Duration of Action: 4-6 hours

Salbutamol primarily works by stimulating which receptors?

Beta-2

How does an opioid overdose kill someone

by depressing level of consciousness and respiratory drive - the patients lose consciousness and stop breathing.

Treatment priorities for an opioid poisoning in the primary survey

Move them to supine for good airway management. Assist their breathing with a BVM attached to high flow oxygen, preferably using a two-person technique. Insert an OPA and prepare your suction for better airway management. Administer naloxone ONLY AFTER you have adequately supported the patient's ventilations. Initiate rapid transport to a higher level of care within 10 minutes of arriving on scene

Pre-game for an opioid poisoning

your patient will be unconscious - consider asking your partner to move to the head to get ready for airway management.

LOC-ABC for an opioid poisoning

1. Check the airway for fluid, suction if necessary, and have your partner apply a jaw thrust once it is clear.

2. 2. Assist respirations with a BVM attached to high flow oxygen at a rate of 1 breath every 5-6 seconds for an adult, every 2-3 seconds for a child or infant.

RBS for an opioid poisoning

. Look for routes of administration, such as needle marks. Checking the pupils can also help verify the mechanism of injury - "pinpoint" or fully constricted, unreactive pupils are a hallmark sign of opioid use.

SOAP for an opioid poisoning

1. Check the oxygen tubing for kinks and the reservoir bag on the BVM to make sure it's filling properly; check the flow rate settings on the oxygen tank to make sure they correct.

   2. Check the patient's pulse oximetry (SpO2).

   3. Prepare your suction and insert an OPA.

Decision point for an opioid overdose (after SOAP is complete)

RTC!!!

1. Request your stretcher.

2. Verify suspicion of opioid use - if you are unsure, check the patient's pupils.

3. Get a set of vitals (including a blood glucose check) and administer one dose of naloxone (Narcan).

4. Move your patient to the stretcher and request other responders to accompany you to hospital, so you can continue to adequately manage airway and breathing enroute.

5. Reassess LOC-ABCi in the ambulance.

Ongoing care for an opioid overdose in the ambulance

1. Perform a vitals check every five minutes, paying special attention to level of consciousness and breathing rate and SpO2.Adjust your treatments if necessary based on what you find.

2. 2. Re-administer naloxone every 5 minutes as indicated.

Classification of naloxone/narcan

Opioid antagonist: attaches to opioid receptors in the brain without triggering an effect; this blocks opioid agonists, such as fentanyl, from attaching to those receptors.

Mechanism of action for naloxone/narcan

Reverses the effects of opioids including respiratory depression, sedation, hypotension. Antagonizes the opioid effects by competing for the same receptor sites.

Indications for naloxone/narcan

Respiratory depression and depressed mental status caused by actual or suspected narcotic use.

Contraindications for naloxone/narcan

KNOWN allergy or hypersensitivity

Cautions for naloxone/narcan

Patient combativeness, especially in polypharmic overdose, May precipitate withdrawal symptoms, especially in patient's dependent on the therapeutic effects of naloxone

Adverse effects of naloxone/narcan

Reversal of narcotic effect and combativeness, Increased pain in patient's dependent on opioid analgesia, Signs and symptoms of severe drug withdrawal, Hypotension, hypertension, Nausea, and vomiting, sweating, tachycardia.

Two possible routes of naloxone/narcan administration (as an EMR)

Intramuscular or intranasal.

dosage(s) for IM naloxone/narcan

can administer up to 4 doses of naloxone via the intramuscular route (every 3 minutes), using the following dosage schedule: Dose 1: 0.4 mg Dose 2: 0.4 mg Dose 3: 0.8 mg Dose 4: 2.0 mg. Only after verifying the medication is still indicated - that the patient's SpO2 is still below 94% and their breathing rate is still below 10 per minute.

Dosage for IN naloxone/narcan

Intranasal naloxone is administered in a single 3 mg spray.

Pharmacokinetics of naloxone

Onset of Action: 3-5 minutes. Peak Action: 5-15 minutes. Duration of Action: 4-6 hours

Why might a second overdose occur in those treated with naloxone

Naloxone's duration of action is often shorter than that of the opioid agonists whose effects it is being used to treat. This means that opioid poisoning patients who have been treated with naloxone are at risk of repeat overdose in 30-45 minutes, and must be kept under observation.

Critical Thinking: After the patient's airway has been secured and breathing is being assisted, why would you check the patient's blood glucose levels before administering naloxone

To rule out a more critical diabetic emergency (hypoglycemia) as the underlying cause of the patient's condition

Key signs to identify opioid poisoning

pinpoint pupils, and respiratory depression or respiraory arrest (and signs of it like needles BUT DONT ASSUME)

Steps of the scene survey

HEMP-RBC -> hazards, environment, MOI, Patients/people, resources (firefighters, ALS, police), Barriers (PPE), condition of patient (LOC? Obvious injuries? age?)

Main steps of the primary survey (abbreviations)

LOC/LOR -> ABCs -> RBS -> SOAP -> decision point (RTC or non-RTC) ->Critical interventions and assessments

Levels of responsiveness in the primary assessment

AVPU -> Alert, Verbal responsive, Pain responsive, Unresponsive.

Secondary survey interview points to cover

CHAMPLE OPQRST -> Chief of complaint, History, Allergies, medications, past medical history, last ins and outs, events prior. Onset, provocation/relief, Quality, Region/radiation, Severity, Time (progression)

How often should vitals be repeated in a RTC case

every 5 mins

How often should vitals be repeated in a Non RTC case

every 15 mins

What is the formula for communicating hospital notifications or clinical consulting

ISBAR -> identification, situation (reason for call), background (time of onset, C.c Hx of C.C, Med Hx) , actions/reactions recommendations/requests ->ETA.

Communication formula for handovers

ATMIST AMBO ->

Age and name,

Time (onset of symptoms and time injury)

MOI or chief complaint,

Injuries,

Signs (vitals),

Treatment (+ response)

Allergies (+ any reactions),

Medications,

Background (past medical history)

Other (any other relevant info)