Paramedic Gems FC

Parts of a scene size up

1. scene safety

2. PPE

3. MOI or NOI

4. number of pts

5. need for additional resources

purpose of a primary survey

identify immediate threats

initiate life-saving interventions without delay

determine pt priority and transport urgency

The ABCDE life support

airway

breathing

circulation

disability (neuro status)

exposure/environment

questions for A

• is airway open?

• is it patent?

• is the pt speaking clearly?

interventions for A

Manuel manuvers (jaw thrust/ head tilt)

suctioning

airway adjuctns (opa/npa)

components of B

rate

rhythm

quality/effort

sounds

interventions for B

administer O2

assist ventilations

treat specific threats (i.e needle decompression)

components of C

pulse

skin

bleeding

interventions for C

direct pressure

manage signs of shock (body temp and fluids)

rapid transport for uncontrolled bleeding or shock

D components

AVPU

pupils

D interventions

c-spine immobilization

assess for hypoglycemia

airway protection

E components

fully expose pts to assess

assess surroundings for hazards

E interventions

cover pt to prevent hypothermia

manage environmental threats

secondary survey purpose

identify all injuries or medical problems

gather pt history

guide definitive care and transport decision

who is a focused exam performed on?

conscious stable pt with an isolated injury or specific medical complaint

directed toward chief complaint and associated body systems

EX: abdonimal assessment for appendicitis

who is a rapid head to toe performed on?

unresponsive, critically injured, or unstable medical pts

quick systematic assessment of entire body to find injuries

components of a secondary assessment

history taking (OPQRST, SAMPLE)

vital sign reassessment

head to toe physical exam

causes for bradypnea

fatigue

overdose

head injury

hypotension causes

dehydration

shock

bleeding

Pharmakinetics and acronym

study of how a drug moves through the body from administration to elimination

ADME (absorbed, distributed, metabolized, excreted)

Immediate vs slow absorption

IV/IO is immediate

PO is slow

what organs receive drugs fastest?

high perfused organs

heart, kidneys, brain

Liver function can affect what in terms of pharmacology?

drug duration and toxicity

pts with liver disease may metabolize drugs slower

how does kidney function affect excretion in terms of pharmacology?

drug elimination rate

poor kidney function can lead to drug accumulation and toxicity

Albuterol MOA

binds to beta 2 receptor in lungs causing bronchial smooth muscle relaxation

agonist

agonist does what?

activates

antagonist does what?

blocks

naloxone MOA

antagonist

blocks opioid receptors reversing overdose effects

Schedule 1 (C-1) examples

heroin

LSD

ecstasy

cannabis

Schedule II (C-II) examples

fentanly

morphine

hydromorphone (diluadid)

oxycodone

methanphentimen

cocaine

schedule III (C-III)

ketamine

hydrocodone with acetamphine

ibupreonphoine

Schedule IV (C-IV) examples

diazepam (Valium)

lorazepam (Ativan)

midazolm (versed)

zoldipem (ambient)

Schedule V (C-V) examples

cough preparations with small amounts of codeine

10 rights of medication administration

1. right pt

2. right drug

3. right dose

4. right route

5. right time

6. right documentation

7. right reason

8. right assessment

9. right response

10. right to refuse

desired dose definition

amount of drug ordered

what you want

concentration definition

the amount od drug per unit of volume

what you have

volume on hand definition

total volume of solution you have

often 1 mL is concentration is mL

volume to administer definition

amount you will draw up and give to pt

drug calculation formula

desired dose (what you want)/ concentration (what you have) x volume on hand= volume to administer

steps to convert to volume administered

1. convert lbs to kilograms

2. calculate desired dose

3. calculate volume to administer

ensure your _____ ___ matches your concentration units (mg/mg, mcg/mcg)

desired dose

what are isotonic solutions?

examples

most common for fluid rescuitaiton

stay within the vascular space and expand circulating volume

normal saline (0.9%)

lactated ringers

what are hypotonic solutions?

examples

lower solute concentration than blood

causes fluid to shift into cells

rarely used in EMS, leads to cellular swelling

dextrose in water

normal saline (0.45%)

what are hypertonic solutions?

examples

higher solute concentration than blood

draws fluids out of cells

used for specific conditions and requires special monitoring

3% normal saline

dextrose 50 (D50)

the 3s of infusion

site

solution

speed

what are symptomimetics?

class of medication designed to mimic the effects of the body’s natural sympathetic nervous system (fight or flight)

alpha 1 receptors location and action

primairly in blood vessels

causes vasoconstriction

beta 1 receptors location and action

heart

increases heart rate and force of contraction

beta 2 receptors action and location

pirmairly in lungs some in blood vessels

causes bronchodilation and some vasodilation

two most common symptomimetics

1. epiniperhine (adrenaline)

2. dopamine (intropin)

epinephrine (adrenaline)

receptor effected

actions

indications

routes/dosing

Alpha-1, beta-1, beta-2 (well rounded)

constricts blood vessels, raises HR, opens airways

anaphylaxis, cardiac arrest, severe ashtma/copd

anaphylaxis= 0.3/0.15mg IM, cardiac arrest= 1mg IV/IO, asthma= nebulized

dopamine (intropin)

receptor effected

actions

indications

routes/dosing

low doses: renal/mesenteric vasodilation, moderate doses: primairly beta 1 effects, high doses: primairly alpha-1 effects

varies from improving kidney blood flow to increasing heart output and raising BP

sympotamic bradycardia and cardiogenic shock

IV/IO infusion 2-20 mcg/kg/min titrated to effect

what are parasympatholytics (anticholingers)?

block effects of parasympathetic nervous system

speed up heart or drying excessive secretions in emergences

parasympatholytics actions

decreases HR

dries secretions

dilates pupils

dilates bronchi

two common parasympatholytics

1. atropine sulfate (atropen)

2. glycopyrrolate (robinul)

atropine sulfate (atropen)

receptor effected

actions

indications

routes/dosing

blocks muscarinic acetylcholine receptors

significantly increases HR, decreased bronchial/salivary secretions, causes pupil dilation

symptomatic bradycardia, organophosphate poisiong/nerve agent exposure

symptomatic bradycardia= 0.5 mg IV/IO repeated 3-5 min

organophosphate poisiong/nerve agent exposure= 2mg IV/IO repeated 3-5 min PRN

glycopyrrolate (robinul)

receptor effected

actions

indications

routes/dosing

anticholingeric, less CNS affects

dries secretions, moderate increase in HR, and minimal bronchodilation

pre-intubation, symtompatic bradycardia

pre-intubation= 0.2 mg IV/IO/IM symtompatic bradycardia= 0.1-0.2mg IV/IO

what are antiarryhtmias?

class of medication used to treat abnormal heart arrhythmias

affect electrical activity of heart aiming to restore normal rhythm

how do antiarryhtmias work?

altering ion channels (sodium, potassium, calcium) in heart cells which control electrical signals

two common antiarryhtmias meds

1. amiodarone (cordorone)

2. diliatziem (cardizem)

amiodarone (cordorone)

receptor effected

actions

indications

routes/dosing

class III antiarryhtmia: potassium channel blocker with effects on sodium/calcium channels and alpha/beta blockade

slows conduciton and stabilizes rhythm

VF and PVT, stable VT

cardiac arrest (VF/pVT)= 300mg IV/IO, followed by 150 mg IV/IO push refractory

stable VT= 150 mg IO/IV over 10 min (infusion)

diliatziem (cardizem)

receptor effected

actions

indications

routes/dosing

calcium channel blocker

slows condition through AV node controlling ventricular rate in certain fast rhythms

rapid ventricular response in a-fib, atrial flutter if hemodynamically stable

A-fib= 0.25 mg/kg IV bolus

what are vasodilators?

medication class designed to relax and widen blood vessels

decreases hearts workload and improve circulation

how do vasodilators work?

relax smooth muscle of veins an arteries

reduces preload (veins) and after load (arteries) of heart

nitroglycerin (nitrostat)

receptor effected

actions

indications

routes/dosing

nitrate, primality a venodilator

relaxes vascular smooth muscle, reduces amount of blood returning to heart, decreased cardiac workload

angina pectoris/ACS, acute pulmonary edema with HTN

sublingual= 0.4 mg tablet/spray every 3-5 min

IV= titrated to effect

nitroprusside (nitropress)

receptor effected

actions

indications

routes/dosing

direct acting venous and arterial dilator

potentially and rapidly relaxes both Venous an arterial smooth muscle, reduction in preload and after load

HTN emergency, severe heart failure, pulmonary edema

IV infusion

two common vasodilators

1. nitroglycerin (nitrostat)

2. nitroprusside (nitropress)

what are analgesics?

relive pain

how do opioid analgesics work?

act on opioid receptors in brain and spinal cord

alter pain reception and provide sedation

two common opioid analgesics

1. morphine sulfate

2. fentanly (duragesic)

morphine sulfate

action

indication

route

opioid analgesia

binds to opioid receptors producing pain relief, sedation, and euphoria, causes vasodilation reducing workload

moderate to severe pain, acute pulmonary edema (cardiogenic)

IV/IO= 2-4 mg slow push, repeated as needed IM= less common slower onset

fentanly (duragesic)

synthetic opioid analgesia (extremely more potent than morphine)

binds to opioid receptors producing potent analgesia and sedation

moderate to severe pn (preferred for pts with hypotension or renal impairment)

IV/IO= 50-100 mcg slow push repeat as needed, IN= 50-100 mcg rapid absporiton

what are sedatives and induction meds?

medication class that calms pts, facilitate uncomfortable procedures, or rapidly induce unconsiucess for rapid airway intervention

what should you always have ready when using sedation/induction meds?

airway adjuncts

main sedatives and induction meds used

1. midazolm (versed)

2. etomidate (amidate)

3. ketamine (ketalar)

midazolm (versed)

class

action

indication

route

side effects

benzodiazepine

produces rapid sedation, amnesia, anxiety reduction, and anticonvulsant properties

seizures, procedural sedation, chemical restraint/agitaiton

IV/IM/IN

resp. distress, hypotension, paradoxical agitation

Retrograde amnesia

type of memory loss where an individual cannot recall events, information, or experiences that occurred before a traumatic event, brain injury, or disease

etomidate (amidate)

class

action

indication

route

side effects

non-barbiturate hypnotic

rapid on-set, ultra short acting that produces immediate loss of conciseness

induction for rapid sequence intubation

IV

myoclonus (muscle twitching in the face)

pain on injection

ketamine (ketalar)

class

action

indication

route

side effects

dissocaitive anestheic

produces dissoassociative state with excellent pain relief and amnesia

pain management, procedural sedative, chemical resistant, rapid sequence intubation induction

IV/IM

emergent reactions (hallucinations), increased secretions, HTN/tachycardia

what are neuromuscular blocks (paralytics) meds?

temporarily paralyze muscles

main use is for rapid sequence intubation

critical safety points of NMBs

paralysis only (only stop movement not consciousness or pain)

ventilate first

monitor constantly

main types of NMB/paralytics

1. succinylcholine (scoline)

2. rocuronium (zemuron)

succinylcholine (scoline)

class

actions

uses

routes/dosing

contraindications

depolarizing NMB

rapid (30-60 sec) ultra short (5-10 min), causes initial twitching

IV/IO 1.0 mg/kg

hx of malignant hyperthermia, severe burns, crush injuries, hyperkalemia

rocuronium (zemuron)

class

actions

uses

routes/dosing

contraindications

non depolarizing NMB

rapid (60-90 sec) intermediate (30-60 min), no twitching

rapid sequence intubation, muscle relaxation during surgery

IV/IO 1.2 mg/kg

hypersensitivity (careful with liver disease)

paramedic gem for succinylcholine (scoline)

2S!

slam dunk for speed

short acting

paramedic gem for rocuronium (zemuron)

2Rs!

roll to rock them out cold

relaxation is longer

cardinal rule of NMB

never a paralytic before a sedative

parts of the upper airway

nose and mouth

pharynx

epiglottis

larynx

what does the epiglottis cover?

trachea during swelling to prevent aspiration

what are the parts of the lower airway?

trachea

lungs

bronchi

bronchioles

alveoli

the right main bronchus is _______ making it more prone to aspiration

wider and straigher

what is ventilation?

physical movement of air in and out of lungs

“what you do”

what is tidal volume?

what is the normal amount?

volume of air moved in a single breath

about 500 ml

what is the minute ventilation?

what is a normal rate?

total air moved per minute (TVxRR)

5-8 L/min

what is respiration?

“what happens”

exchange of o2 and co2

what is the ventilation perfusion ratio (V/Q)?

normale rate

V= how much air getting to the alveoli (normal= 4 L/min)

Q= how much blood flows around them (normal= 5 L/min)

normal ratio= 0.8 L/m

mismatch= poor gas exchange

key principles of suctioning

dont suction for longer than 10-15 sec

suction on withdrawal

what are supraglottic airways? (SGAs)

designed to provide a secure airway seal in pharynx and larynx, directing air into the trachea without entering it

How do supraglottic airways work?

1. create a seal around the glottic opening

2. allow positive pressure ventilation (like a BVM) to inflate the lungs