KAAP 608 Exam 2

Nebulized Medication Administration

-Using compressed air or ultrasonic power to turn medication solution into droplets that are inhaled

-Tubing that connects to an oxygen source to a small cup that holds medication and either a mouthpiece or face mask.

Emergency Medication Injection

Drawing up Medications

Subcutaneous (skin)

Intermuscular (Muscle)

Intervenous (Vein)

6 rights to emergency medication administration

dose, patient, time, route, documentation, time

Administering epinephrine auto-injector

1. Inspect the patient's lateral thigh

2. Remove the auto-injector from the carrier tube. Check that the medication is not expired and is clear.

3. Hold formly with the orange tip pointing downward. Remove the blue safty cap by pulling straight up, do not bend or twist

4. Swing and push orange tip firmly into mid-outer thigh until you hear a "click". Hold on thigh for several seconds.

5. Call 911

Administering epinephrine

Delays the patient's symptoms, does not treat

Activate EMS

Narcan

Reverse the effects of opioids, remove binding sites

Sudden Death in Athletes

• Cardiovascular Disease

• Cervical Spine Injury

• Commotio Cordis (chest wall)

• Blunt force trauma (head or spine)

• Heat Stroke

• Hyponatremia

• Sudden Cardiac Arrest

• Lightning Strike

Early activation of EMS and high-quality CPR

What are the most important life-saving steps you can take in an emergency?

Direct fatality

A fatality caused by participation in a fundamental skill (ex., head trauma)

Indirect fatality

A fatality caused by the body system failure as a result of exertion (ex. cardiac failure)

Fall Sports

Indirect was 2x larger than direct

70% of football indirect deaths were heat/heart related

Winter Sports

Indirect fatalities outnumbered direct fatalities

Spring Sports

All direct fatalities (n=21) in high school were head/neck

-17/21 direct in high school were in pole vaulting

-30/37 indirect fatalities in high school track were heart-related

The most common causes of death in organized sports

-Cardiac

-Head Injuries

-EHS

-Exertional sickling

-Asthma

-trauma

-Neck injuries

-Other (lightning, diabetes, etc.)

Develop emergency action plans

To specify prevention, recognition, treatment, and return-to-play guidelines for each condition.

Challenging Circumstances

-Many organized sports settings do not have medical staff on-site

-Coaches and other personnel involved with organized sports are responsible for recognition and treatment of life-threatening medical emergencies

-Major concern due to most common life-threatening injuries having similar signs and symptoms

Challenging Circumstances

-Nearly all emergency medical conditions need to be properly dealt with within the first few minutes

-It is recommended that coaches be trained in first aid, CPR, and AED use for immediate first responder care

-Every highschool should have an on-site AT

Sudden Cardiac Arrest

Occurs when the heart develops an abnormal rhythm (electrical or structural heart problem)

Heart Attack (Myocardial Infarction)

occurs due to the loss or dramatic decrease of blood supply to the heart muscle

Sudden Cardiac Death

Refers to the death of an individual during or within 1 hour after exercise due to a cardiovascular disorder

Background and Occurrence

• Leading cause of death in young athletes (ages12−35) during exercise

• Three-fold greater risk of sudden cardiac death in young athletes than non-athletes

• Two to nine-fold cases of sudden cardiac death in males than females

• Three-fold greater risk of sudden cardiac death in black athletes than white athletes

• Prevalent in basketball and football

Mechanisms and causes of SCA

-Electrical signal turns into ventricular fibrillation during SCA

-Survival rate decreases by 7-10% with each minute

-AED allows one to give an electrical shock to normalize the heart rhythm

-Cardiopulmonary resuscitation done before and after using AED

Specific causes of SCA

-Hypertrophic cardiomyopathy

-Coronary artery anomalies

-Myocarditis

-Arrhythmogenic right ventricular cardiomyopathy

-Aortic rupture/marfan syndrome

-Ion channel disorders

-Commotio Cordis

Hypertrophic cardiomyopathy

-Causes 1/3 of SCD in young athletes in the U.S

-Thickening of the muscle walls of the left chamber and in the walls that separate the 2 lower chambers

-Muscle fibers become disorganized, electrical signal disrupted

-Screening tests are not useful before high school

Coronary Artery Anomalies

-Causes 15% of SCD in young athletes in the U.S

-Abnormalities in the blood vessels on the surface of the heart that supply the muscle walls

-Abnormalities can shut off the blood flow to the muscle walls of the heart

Changes in electrical signals, SCA

Myocarditis

-Causes 7% of deaths in young athletes in the U.S

-Non-communicable viral inflammation of the heart muscle

-Can occur with no prior heart problem

-Inflammation and scar tissue formation

-Changes in electrical signal, SCA

-Enlargement of the heart (dilated chambers)

Aortic Rupture/Marfan Syndrome

Marfan syndrome is an inherited problem with C.T

-above average height, long limbs, long fingers, increased flexibility

The first part of the aorta becomes dilated and weak (risk of aortic rupture)

Commotio Cordis

-cardiac concussion

-occurs as a result of blunt trauma (changes electrical signal, SCA)

-Most common in adolescent boys

-Chest protector has not yet been proven to prevent this

Mechanism, causes, and recognition of commotio cordis

-Small projectile with a dense core that tends to be propelled at a high velocity (baseball, hockey, lacrosse)

-Impact over the left side of the heart

-Half of the reported victims collapsed instantaneously

Mechanism, causes, and recognition of commotio cordis

-VF is seen in the majority of patients with attempted resuscitation

-Most commonly seen in the young (13-19)

-Males account for 95% of cases

Prevention of Sudden Death

Screening for underlying heart problems

-AHA estimates 1 in 300 young adults have an underlying heart problem

-Heart Screenings

Heart Screenings

-Symptoms

-Family History

-Physical Exam

-ECG

ECG

-recording of the electrical signals of the heart

-cost

-feasibility

-false-positive rate

-15% over two decades ago

-recent studies 2-3%

Recognition of Sudden Death before collapse

Before an athlete collapses

-Many do not have symptoms before collapse

-VF will quickly result in a collapse

-Athletes may complain of:

chest pain

lightheadiness

racing heartbeat

Recognition of Sudden Death after collapse

After an athlete collapses

-Responsibility of medical staff, coaches, refs, other support staff, and other athletes

-Suspect SCA when an athlete collapses and is unresponsive

-May mimic a seizure

Recognition of Sudden Death after collapse

After an athlete collapses

-Assessment of breathing and pulse

-Evaluate for differential diagnosis after normal breathing, a definitive pulse, and heart rhythm analysis by an AED are confirmed

Management

• Develop an emergency action plan.

• Identify and train likely responders in CPR and AED use.

• Establish a communications system.

• Ensure an adequate number of AEDs that allow the responder to access

the AED within 3 to 5 minutes from the time of collapse.

• Integrate and register the AED with the local EMS system.

Management

Goals and objectives within 10−15 minutes of onset

• Recognition of SCA

• Early activation of the EMS system; call 911

• Early CPR

• Immediate retrieval of the AED

• Application of the AED as soon as possible

• Placement of a breathing tube and administration of medications by

trained medical professionals, if needed

RTP

-consult cardiologist: temporarily or permanently be restricted from certain activities or sports depending of the underlying heart problem

-Recommendations from the 36th Bethesda Conference by the American College of Cardiology

-Must consider the severity of the underlying problem

-Risk of sudden death

-Type & Intensity of exercise

Surgical interventions

-catheter ablation

pacemaker/defibrillator implant

simple triage and rapid treatment

What does start stand for?

RPM

R- yes or no, >30 bpm

P-radial pulse or cap refill

M- altered or confused

Sort, assess, life-threatening interventions, treatment/transport

What does SALT stand for?

Sort

Green: minor injuries

Yellow: Serious injuries (watch them, but treatment can be delayed)

Red: Severe injuries (immediate medical attention increases the likelihood of surviving)

Black: injuries too severe, treatment will not help survival

Assess

Vital signs:

-respiration

-breathing

-pulse

-BP

-pupils

-Mental Status

-quick visual exam of body looking for fluids/blood

Life-threatening interventions

cardiac, severe bleeding, allergic reaction, diabetic emergency

treatment/transport

CPR, epinephrine, cold bath, stop bleeding, blankets

How are they getting there?

Emergency Department?

Circulatory System

-In emergencies, blood is redirected to critical organs

-Perfusion and hypoperfusion

-A dynamic system

-Components of blood:

plasma, RBCs, WBCs, and platelets

hypoperfusion

a decrease in blood to tissues, which causes obstruction, blood loss, and a malfunctioning heart

Purpose of blood

-thermoregulation

-deliver blood and nutrients to the body

-Remove waste products

-fight infection

Perfusion

-Oxygen and nutrients are provided to the tissue and metabolic waste products are removed via the circulating blood

-Reduction in perfusion (various causes) leads to impaired cellular function

Hemorrhage

-Acute and significant blood loss decreases blood volume

-blood volume loss and duration of bleeding dictate severity

-life-threatening hemorrhage can lead to sepsis and/or multiple organ failure

-Possible complications: DVT and hypercoagulation

-Responsible for 35% of pre-hospital deaths

-The Army considers hemorrhage a preventable cause of death on the battlefield

decreases blood volume

What does significant blood loss do?

dictates severity

blood volume loss and duration of bleeding

Factors contributing to hemorrhage severity

Age

Severity of injury, anatomic location

time lapse between injury and initiation of treatment

pre-hospital treatment available

medications used for chronic conditions

Possible complications with hemorrhaging

DVT and hypercoagulation

components of blood

plasma, RBCs, WBCs, and platelets

External hemorrhage

Bleeding is visible, controlled via direct pressure or pressure bandage

Internal hemorrhage

not typically visible, often identified later in the assessment, and usually controlled by the surgeon

Ecchymosis

bruise

Epistaxis

nosebleed

Hematemesis

vomiting blood

Hemoptysis

coughing up blood

Purpura

small blood vessel burst, causing blood to pool under the skin

Process of hemostasis

-Vascular Spasm

-Formation of platelet plug

-Development of a clot (DVT, hemophilia)

Systemic responses to acute hemorrhage

-Hormone response to contrict vessels = Increased HR and Increased CO

-Urine output decreases, and thirst is signaled

-Mental status changes: weakness, dizziness, anxiety

-Catecholamines released

-Respiratory rate increases to offset metabolic acidosis (increases CO2 in blood)

Assessment of a patient with hemorrhage

Rapid assessment to determine the source of bleeding

Thorough physical exam

- Large-scale bleeding locations:

-external hemorrhage (anywhere on body)

-thoracic cavity

-peritoneal cavity

-retroperitoneal cavity

-muscle or subcutaneous space (long-bone cavity)

Internal hemorrhage

-S/S onset can be delayed

-Result from trauma to the thorax or abdomen

-Patient will require prompt transport to an emergency facility

-Two types of trauma (blunt and penetrating)

Most serious internal bleeding

-Intracranial hemorrhage

-Hemothorax

-Hemopericardium

Aorta, superior, and inferior vena cava

Organ damage: liver and spleen

Hemothorax

blood in the pleural space (area between the lung and the chest wall)

Hemopericardium

blood in the pericardial sac (space surrounding the heart)

Delayed S/S of Internal Hemorrhage

-lightheadedness, dizziness, or fainting

-headache, seizures, loss of consciousness

-large area of ecchymosis

-swelling, tightness, and pain in extremities or abdomen

-Kehr's sign

Kehr's Sign

Acute pain at the tip of the shoulder due to blood or other irritants in the peritoneal cavity when a person is lying down with the legs elevated. Left shoulder pain is considered a classic symptom of a ruptured spleen.

McBurney's Point

A point on the right side of the abdomen, about two-thirds of the distance between the umbilicus and the anterior bony prominence of the hip

Melena

black stool, usually from GI

Hematochezia

Fresh blood in stool, usually from the colon

Steps for controlling external bleeding

-Use standard precautions

-Maintain the airway with spinal motion restriction if spinal injury is suspected

-Apply direct pressure over the wound with a dry, sterile dressing

-If bleeding continues, do not remove dressing; instead, apply additional dressing with manual pressure

Steps for controlling external bleeding

If bleeding continues, apply a pressure bandage

-Cover the entire dressing above and below the wound

-Stretch band tight enough to control bleeding but not so tight as to decrease blood flow to the extremity

Check distal pulse (on injured extremity) before and after applying dressing

If direct pressure and a pressure dressing are not immediately effective, apply a tourniquet above the level of the bleeding or use a hemostatic agent

Steps for controlling external bleeding

-If a tourniquet is not possible because the bleeding is too far or a hemostatic agent is unavailable, apply direct pressure and maintain pressure until the patient is transferred to the ED

-Apply high-flow oxygen (10-15 mL/min) as necessary, once hemorrhaging is controlled

-Do not remove the dressing until a physician has evaluated the patient

Hemostasis agents

-Anatomical areas difficult to apply direct pressure

-The granules or dressing absorb water from blood to concentrate the clotting factors

-Nonprescription topical product

-Can be removed by soaking with hydrogen peroxide

Wound Closure

-determine severity

-Clean wound: 1:10 mixture of povidone/iodine solution and isotonic saline

-Debridement: removal of foreign bodies, dead and/or devitalized tissue

-Closure: skin adhesives, adhesive strips, metal staples, or sutures

Sutures

-sizes

-needles

-technique

-knot tying: two-handed square knot

-after suture care and complications

-suture removal

Touriquets

-Do not apply directly over a joint; apply proximal and adjacent to the injury

-Tighten securely

-Never use wire, rope, belt, or other narrow material

-Use wide paddling under the tourniquet if possible

Never cover a tourniquet with a bandage; leave it open and in full view

-Write the day and time it was applied to the patient's skin

Shock

resulting from inadequate tissue perfusion (hypoperfusion)

Results from uncontrolled hemorrhage

-inadequate oxygenation

-mechanical obstruction

-neurologic dysfunction

-cardiac dysfunction

Stages of Shock

1. Pre-shock or compensated shock

-decrease tissue perfusion

2. Uncompensated shock

-tachycardia, dyspnea, restlessness

3. Reperfusion

-Ischemic

4. Multiple organ failure

-irreversible organ failure

5. death

Hypovolemic shock

decreased blood volume (internal/external bleeding)

Distributive shock

vasodilatory (blood pulls on extremities)

Cardiogenic Shock

heart can't pump, abnormal cardiac rhythm

Obstructive shock

blocked vessel, blood vessel obstructed

Red flags for recognition of shock

• Cool, clammy skin, diaphoresis, pallor, cyanosis, restlessness

• Ill appearance, altered mental status

• Tachycardia - Increased HR

• Tachypnea - Increased RR

• Hypotension

• Weak peripheral pulses, narrowing of the pulse pressure

• Prolonged capillary refill

Emergency Care for Undifferentiated Shock

• Recognize the state of shock

• Establish a patent and protected airway

• Maintain adequate oxygen delivery

• Limit blood loss by controlling external hemorrhage

• Restore intravascular volume by initiating fluid resuscitation via IV

• Cover the patient to maintain normal body temperature

• Rapidly transport the patient to the appropriate trauma center

Anaphylaxis

sudden release of mast cells and basophil-derived mediators that release histamine

Exaggerated immune response

release of immunoglobulin E antibodies

Risk Factors of increased severity

• Recent episode of anaphylaxis

• Extremes of age (very young or very old)

• Presence of cardiopulmonary conditions

• Taking medications that may influence the timely recognition of symptoms

• Rapid onset of symptoms after exposure

dependent

Most common trigger:

food

venom

anti-biotic

independent

-NSAIDS

-Biological Agents

S/S of anaphylaxis

Skin and/or mucosal tissue: 80-90% present with this

-hives

-pruritus

-angioedema

-flushing or diaphoresis

Respiratory compromise

-dyspnea

-wheezing or bronchospasm

-stridor

-cough or voice change

Reduced BP or associated end-organ dysfunction involvement

-hypotension

-collapse or sudden weakness

-syncope

GI symptoms (least common)

-nausea

-vomiting

-diarrhea

Source of anaphylaxis

Food-dependent exercise-induced anaphylaxis (FDEIA)

-usually associated with physical activity

-reaction within 15-30 min of initiating activity

insect bites/stings

drugs/medications

Emergency care for anaphylactic reactions

-ABCDE (airway, breathing, circulation, disability, exposure)

-Pharmacological intervention, epinephrine

-Education and prevention are key

Nerves of the UE

Axillary, musculocutaneous, radial, medial, and ulnar

Blood vessels of the UE

subclavian, axillary, circumflex, brachial, radial, and ulnar arteries