cardiac & nervous system emergencies september 2010 ce condell medical center ems system...

Cardiac & Nervous SystemEmergencies

September 2010 CESeptember 2010 CECondell Medical Center EMS System Condell Medical Center EMS System

Prepared by: FF/PMD Michael MountsPrepared by: FF/PMD Michael MountsLake Forest Fire DepartmentLake Forest Fire Department

Reviewed/revised by: Dr. Kent Bailey, EMS Medical DirectorReviewed/revised by: Dr. Kent Bailey, EMS Medical Director

Objectives Identify components of the nervous system Identify components of the nervous system Identify signs and symptoms of a patient with a Identify signs and symptoms of a patient with a

CVA CVA Identify assessment & field treatment of patient Identify assessment & field treatment of patient

with a CVA with a CVA Identify anatomy and physiology of the cardio-Identify anatomy and physiology of the cardio-

pulmonary system pulmonary system Identify signs and symptoms of a patient with Identify signs and symptoms of a patient with

ACSACS Identify field treatment of patient with ACSIdentify field treatment of patient with ACS

Objectives cont. Discuss situations for using the RAD 57 toolDiscuss situations for using the RAD 57 tool Identify patient care based on RAD 57 Identify patient care based on RAD 57

readingsreadings Review documentation components for Review documentation components for

discussed conditionsdiscussed conditions Identify a variety of ECG rhythm stripsIdentify a variety of ECG rhythm strips Demonstrate 12-lead ECG applicationDemonstrate 12-lead ECG application Demonstrate use of RAD 57 deviceDemonstrate use of RAD 57 device

Components of the CNS Brain - 3 major structuresBrain - 3 major structures

CerebrumCerebrum largest element of nervous systemlargest element of nervous system occupies most of craniumoccupies most of cranium highest functional portion of brainhighest functional portion of brain center of conscious thought, personality, speech, center of conscious thought, personality, speech,

motor control, and visual, auditory, & tactile motor control, and visual, auditory, & tactile perceptionperception

CerebellumCerebellum fine tunes motor control, allows smooth motion fine tunes motor control, allows smooth motion

from one position to anotherfrom one position to another responsible for balance & maintenance of muscle responsible for balance & maintenance of muscle

tonetone

BrainstemBrainstem• central processing center &communication central processing center &communication

junctionjunction• midbrainmidbrain

• hypothalamushypothalamus• controls much of endocrine function, vomiting controls much of endocrine function, vomiting

reflex, hunger, thirst, kidney function, body reflex, hunger, thirst, kidney function, body temperaturetemperature

Components of the CNS cont.

• Brainstem cont.Brainstem cont.• ponspons• medulla oblongatamedulla oblongata

• respiratory center (depth, rate, rhythm)respiratory center (depth, rate, rhythm)

• cardiac center (rate & strength of cardiac cardiac center (rate & strength of cardiac contractions)contractions)

• vasomotor center (control of distribution of blood vasomotor center (control of distribution of blood and maintenance of blood pressure)and maintenance of blood pressure)

Components of the CNS cont.

1. Skull bone

2. Periosteum of

the skull

3. Dura

4. Arachnoid

5. Subarachnoid

space

6. Pia mater

In order…skull

periosteum

dura

Cross-section of the brain

CNS Circulation

4 major arterial vessels4 major arterial vessels Capillaries uniqueCapillaries unique

walls thicker so they are walls thicker so they are less permeableless permeable

protected environment via protected environment via the blood-brain barrierthe blood-brain barrier

Cerebral perfusionCerebral perfusion changes in ICP are met changes in ICP are met

with compensatory changes with compensatory changes in blood pressurein blood pressure

Cerebral Perfusion Pressure

Intracranial pressure - pressure within craniumIntracranial pressure - pressure within cranium pressures within cranium create a natural resistance to pressures within cranium create a natural resistance to

control the amount of cerebral blood flowcontrol the amount of cerebral blood flow blood flow to the brain remains adequate as long as blood flow to the brain remains adequate as long as

pressures within the cranium are appropriatepressures within the cranium are appropriate

3 major cranial contents3 major cranial contents brain, brain, blood, & blood, & cerebrospinal fluidcerebrospinal fluid

Any changes in one of the 3 cranial contents is at the Any changes in one of the 3 cranial contents is at the sacrifice to one of the otherssacrifice to one of the others

When ICP rises, the body increases the BP to maintain When ICP rises, the body increases the BP to maintain the cerebral perfusion (Cushing reflex)the cerebral perfusion (Cushing reflex)

How the brain works…

Locations of function within the brainLocations of function within the brain Review from JulyReview from July

Left vs. Right brain thought processLeft vs. Right brain thought process Functional differencesFunctional differences

Brain function locations Frontal LobeFrontal Lobe - reasoning, - reasoning,

planning, parts of speech, planning, parts of speech, movement, emotions, and movement, emotions, and problem solving problem solving

Parietal LobeParietal Lobe - movement, - movement, orientation, recognition, orientation, recognition, perception of stimuli perception of stimuli

Occipital LobeOccipital Lobe - visual processing - visual processing Temporal LobeTemporal Lobe - perception and - perception and

recognition of auditory stimuli, recognition of auditory stimuli, memory, and speech memory, and speech

CerebellumCerebellum - regulation and - regulation and coordination of movement, coordination of movement, posture, and balance posture, and balance

Brain stemBrain stem - breathing, heartbeat, - breathing, heartbeat, and blood pressureand blood pressure

Remember (from July)…

Wernicke’s AreaWernicke’s Area Controls speech comprehensionControls speech comprehension

Broca’s AreaBroca’s Area Controls speech productionControls speech production

Both on left side of brainBoth on left side of brain If either of the above speech If either of the above speech

areas are noted to be affected, areas are noted to be affected,

see if right sided weakness see if right sided weakness

is also presentis also present Speech and motor problems will be reflected Speech and motor problems will be reflected

on opposite sides of the bodyon opposite sides of the body

Left vs. Right This theory of the structure and functions of the mind This theory of the structure and functions of the mind

suggests that the two different sides of the brain control suggests that the two different sides of the brain control two different “modes” of thinking. It also suggests that two different “modes” of thinking. It also suggests that each of us prefers one mode over the other. each of us prefers one mode over the other.

Left BrainLogical

SequentialRational

AnalyticalObjective

Looks at parts

Right BrainRandom IntuitiveHolistic

SynthesizingSubjective

Looks at wholes

Left vs. Right cont.

Note: Notice how Broca & Wernicke’s area are on Left side

Hearing difference: Speech on Left vs. Music on Right

CVA Signs and Symptoms

Trouble with walking, sudden dizziness, loss of Trouble with walking, sudden dizziness, loss of balance or loss of coordination. balance or loss of coordination.

Trouble with speaking and/or understanding, Trouble with speaking and/or understanding, confusion, slurred words or be unable to find the right confusion, slurred words or be unable to find the right words to explain what is happening (aphasia).words to explain what is happening (aphasia).

Paralysis or numbness on one side of the body or Paralysis or numbness on one side of the body or face.face.

Trouble with seeing in one or both eyes. Sudden Trouble with seeing in one or both eyes. Sudden blurred or blackened vision, or seeing double. blurred or blackened vision, or seeing double.

Headache; a sudden, severe "bolt out of the blue" Headache; a sudden, severe "bolt out of the blue" headache, which may be accompanied by vomiting, headache, which may be accompanied by vomiting, dizziness or altered consciousness.dizziness or altered consciousness.

What to do…

Initial assessmentInitial assessment AVPU, ABC’s, life threats, etc.AVPU, ABC’s, life threats, etc. Sample historySample history VitalsVitals PupilsPupils GlasgowGlasgow Time of onset Time of onset VERYVERY important! important!

F.A.S.T. or Cincinnati Stroke ScaleF.A.S.T. or Cincinnati Stroke Scale Remember…Remember… you only need to have one of you only need to have one of

these signs for positive CVA identification.these signs for positive CVA identification.

Cincinnati Stroke Scale or FAST

F – look for F – look for ffacial droopingacial drooping Have patient smile large enough to see Have patient smile large enough to see

teethteeth A – check for A – check for aarm driftrm drift

Patient holds hands out in front for 10 Patient holds hands out in front for 10 seconds with eyes closed, palms upseconds with eyes closed, palms up

S – check for slurred S – check for slurred sspeechpeech T – teach patients to call 911 – T – teach patients to call 911 – ttime is ime is

essential essential

Facial Drooping

Ask the patient to smile real big and show you their Ask the patient to smile real big and show you their teethteeth Best way to see if a droop is presentBest way to see if a droop is present

Arm Drift

Demonstrate first and then have patient hold their Demonstrate first and then have patient hold their hands out in front, palms up, for 10 secondshands out in front, palms up, for 10 seconds

Clarity of Speech

Most likely you’ll know by now if there is a Most likely you’ll know by now if there is a speech problemspeech problem

Can have the patient repeat after you any Can have the patient repeat after you any words or a sentence you give themwords or a sentence you give them

““You can’t teach an old dog new tricks”You can’t teach an old dog new tricks”

7 D’S Of Stroke Care

DetectionDetection – of signs and symptoms – of signs and symptoms DispatchDispatch – call 911 – call 911 DeliveryDelivery – to the appropriate facility – to the appropriate facility DoorDoor – emergent triage in the ED – emergent triage in the ED DataData – appropriate tests – appropriate tests DecisionDecision – to administer a fibrinolytic or not – to administer a fibrinolytic or not DrugDrug – must administer the fibrinolytic within – must administer the fibrinolytic within

3 hours of onset of symptoms3 hours of onset of symptoms

Intracranial HemorrhagesIntracranial Hemorrhages Epidural – rapid onset, traumaticEpidural – rapid onset, traumatic

Arterial bleedArterial bleed Headache Headache Nausea/vomiting Nausea/vomiting Seizures Seizures Focal neurologic deficits (aphasia, Focal neurologic deficits (aphasia,

weakness, numbness)weakness, numbness) Subdural – slower onset, traumaticSubdural – slower onset, traumatic

Venous bleedVenous bleed Symptoms are often vagueSymptoms are often vague Usually altered mental statusUsually altered mental status Seen more often in elderly; brain Seen more often in elderly; brain

atrophy stretches the veins, making atrophy stretches the veins, making them more likely to tear in traumathem more likely to tear in trauma

*Note*Note - White area is bleeding - White area is bleeding

Intracranial HemorrhagesIntracranial Hemorrhages Subarachnoid – sudden onsetSubarachnoid – sudden onset

Usually from berry aneurysm rupture Usually from berry aneurysm rupture from the base of the brain; bleeding from the base of the brain; bleeding around the brain (mixed with the around the brain (mixed with the CSF)CSF)

Usual spontaneous, non-traumaticUsual spontaneous, non-traumatic Sudden severe headacheSudden severe headache VertigoVertigo Light sensitivityLight sensitivity Often altered mental statusOften altered mental status

Intraparenchymal (inside brain Intraparenchymal (inside brain tissue)tissue)

Traumatic bleed or spontaneous Traumatic bleed or spontaneous rupture of AVM (arteriovenous rupture of AVM (arteriovenous malformation)malformation)

Region X Protocol STROKE / BRAIN ATTACK (pg. 26)

Cardio-Pulmonary A&P

We need to know what is being We need to know what is being affected and how that is shown as affected and how that is shown as sign and/or symptomssign and/or symptoms

Knowing the following general Knowing the following general A&P will assist in assessmentA&P will assist in assessment VeinsVeins ArteriesArteries Other tissuesOther tissues

Cardiac A&P review

Coronary Circulation Coronary arteries and veinsCoronary arteries and veins Myocardium extracts the largest amount of Myocardium extracts the largest amount of

oxygen as blood moves into general oxygen as blood moves into general circulationcirculation

Oxygen uptake by the myocardium can only Oxygen uptake by the myocardium can only improve by increasing blood flow through the improve by increasing blood flow through the coronary arteriescoronary arteries

If the coronary arteries are blocked, they must If the coronary arteries are blocked, they must be reopened if circulation is going to be be reopened if circulation is going to be restored to that area of tissue suppliedrestored to that area of tissue supplied

The Electrical Conduction System

SA NodeSA Node

AV NodeAV Node

Bundle of HISBundle of HIS

Purkinje FibersPurkinje Fibers

SA nodeSA node: : Fastest rate of automaticity automaticity. Fastest rate of automaticity automaticity. “Primary” pacemaker of the heart. Rate: 60 to 100 “Primary” pacemaker of the heart. Rate: 60 to 100 bpmbpm

AV nodeAV node: : Has a delay which allows for atrial Has a delay which allows for atrial contraction and a more filling of the ventricles. contraction and a more filling of the ventricles. Rate: 40-60 bpm Rate: 40-60 bpm (if not driven by the rate above)(if not driven by the rate above)

Bundle of HisBundle of His: : Has the ability to self-initiate Has the ability to self-initiate electrical activity Rate: 40-60 bpmelectrical activity Rate: 40-60 bpm

Purkinje FibersPurkinje Fibers: : Network of fibers that carry Network of fibers that carry electrical impulses directly to ventricular muscle. electrical impulses directly to ventricular muscle. Rate: 20-40 bpm Rate: 20-40 bpm (if not driven by the rate above)(if not driven by the rate above)

The Electrical Conduction System cont.

The Electrical Conduction System in motion

Electrocardiogram(ECG/EKG)

Its name is made of 3 different parts:Its name is made of 3 different parts: electroelectro, because it is related to , because it is related to

electrical activityelectrical activity cardiocardio, Greek for heart, Greek for heart

gramgram, a Greek root meaning "to write", a Greek root meaning "to write"

12-Lead Electrodes

A lead is a tracing of the electrical activity A lead is a tracing of the electrical activity between 2 electrodesbetween 2 electrodes

Leads view the heart from the front of the bodyLeads view the heart from the front of the body Top, bottom, right, and left side of heartTop, bottom, right, and left side of heart

Leads view the heart as if it were sliced in half Leads view the heart as if it were sliced in half horizontallyhorizontally Front, back, right, and left sides of heartFront, back, right, and left sides of heart

Each lead has a positive and a negative electrodeEach lead has a positive and a negative electrode

12-lead ECG A 12-lead ECG is made up of a tracing of the electrical A 12-lead ECG is made up of a tracing of the electrical

activity of the heart from 12 different points of view. activity of the heart from 12 different points of view. The point of view comes from the location of the The point of view comes from the location of the positive electrode of each lead. The positioning of positive electrode of each lead. The positioning of these electrodes is broken down into these electrodes is broken down into 3 categories3 categories;;

The limb leads (lead I, II & III)The limb leads (lead I, II & III) The augmented leads (aVR, aVL & aVF)The augmented leads (aVR, aVL & aVF) The precordial/chest leads (V1, V2, V3, V4, V5,V6)The precordial/chest leads (V1, V2, V3, V4, V5,V6)

Standard 12-Lead EKG

Six limb leadsSix limb leads Leads I, II, III, aVR, aVL, aVFLeads I, II, III, aVR, aVL, aVF

Six chest leads (precordial leads)Six chest leads (precordial leads) V1, V2, V3, V4, V5, V6V1, V2, V3, V4, V5, V6

Information from 12 leads obtained from Information from 12 leads obtained from the attachment of only 10 electrodesthe attachment of only 10 electrodes

Contiguous ECG Leads EKG changes are EKG changes are

significant when they significant when they are seen in at least two are seen in at least two contiguouscontiguous leads leads

Two leads are Two leads are contiguous if they look contiguous if they look at the same area of the at the same area of the heart or they are heart or they are numerically numerically consecutive chest leadsconsecutive chest leads

12-Lead Electrode Placement

Lateral Wall MI: I, aVL, V5, V6

Source: The 12-Lead ECG in Acute Coronary Syndromes, MosbyJems, 2006.

Complications of Lateral Wall MI I, aVL, V5,V6I, aVL, V5,V6

Complications arise due to the conduction Complications arise due to the conduction components that are in the septumcomponents that are in the septum

Conduction dysrhythmias most commonConduction dysrhythmias most common Second degree Type II – classicalSecond degree Type II – classical 33rdrd degree – complete heart block degree – complete heart block Bundle branch blocksBundle branch blocks

Monitor patient closely for these blocksMonitor patient closely for these blocks 22ndnd degree Type II and 3 degree Type II and 3rdrd degree are serious degree are serious

dysrhythmias that need to be treated aggressively with dysrhythmias that need to be treated aggressively with TCPTCP

Inferior Wall MI: II, III, aVF


Complications of Inferior Wall MI II, III, aVFII, III, aVF

40% of patients with inferior MI’s have right ventricular 40% of patients with inferior MI’s have right ventricular infarcts infarcts

In the presence of a right ventricular infarct, there is a high In the presence of a right ventricular infarct, there is a high likeliness of both ventricles being damagedlikeliness of both ventricles being damaged

Contraction capabilities will be negatively affectedContraction capabilities will be negatively affected Patients may present hypotensivePatients may present hypotensive Nitrates and Morphine alone will dilate blood vessels Nitrates and Morphine alone will dilate blood vessels

worsening hypotensionworsening hypotension Under Medical Control direction patients are often treated Under Medical Control direction patients are often treated

with a fluid challenge with the nitrates with a fluid challenge with the nitrates 11stst degree heart block and Second degree Type I degree heart block and Second degree Type I

Wenckebach most common heart blocksWenckebach most common heart blocks

Septal MI: V1 and V2


Complications of Septal Wall MI V1 and V2V1 and V2 Significant amount of conduction components Significant amount of conduction components

are in the septal areaare in the septal area Patient predisposed to dysrhythmiaPatient predisposed to dysrhythmia

Second degree Type II – classicalSecond degree Type II – classical 33rdrd degree heart block degree heart block Bundle branch blockBundle branch block

Lethal heart blocks treated aggressively - TCPLethal heart blocks treated aggressively - TCP Rare to have a septal MI aloneRare to have a septal MI alone

Common to have anterior or lateral involvement Common to have anterior or lateral involvement along with septal areaalong with septal area

Anterior Wall MI: V3, V4


Complications of Anterior Wall MI V3, V4V3, V4 Known as the “widowmaker” due to the potential Known as the “widowmaker” due to the potential

for a massive area of infarction from blockage of for a massive area of infarction from blockage of the large amount of myocardium supplied by the the large amount of myocardium supplied by the LAD (left anterior descending artery)LAD (left anterior descending artery)

Often the septal or lateral walls are also involvedOften the septal or lateral walls are also involved Watch for lethal ventricular dysrhythmias and Watch for lethal ventricular dysrhythmias and

cardiogenic shockcardiogenic shock Second degree Type II and 3Second degree Type II and 3rdrd degree heart block degree heart block

are more common than other blocksare more common than other blocks

Anterior Wall MI cont.

Early death within a few days often from CHFEarly death within a few days often from CHF Massive area of ventricular tissue infarcted if Massive area of ventricular tissue infarcted if

LAD totally occludedLAD totally occluded Important to obtain history of recent MI diagnosis Important to obtain history of recent MI diagnosis

and hospital dischargeand hospital discharge Increased incidence of ventricular Increased incidence of ventricular

tachycardia (VT) and ventricular fibrillation tachycardia (VT) and ventricular fibrillation (VF) up to 1 -2 weeks post acute anterior (VF) up to 1 -2 weeks post acute anterior MIMI

Posterior MI: Reciprocal Changes ST Depression V1, V2, V3, poss V4


Atypical Presentation in the Elderly

Most frequent symptoms of acute MI:Most frequent symptoms of acute MI: Shortness of breathShortness of breath Fatigue and weakness (“I just don’t feel well”)Fatigue and weakness (“I just don’t feel well”) Abdominal or epigastric discomfortAbdominal or epigastric discomfort

Often have preexisting conditions making this Often have preexisting conditions making this an already vulnerable populationan already vulnerable population HypertensionHypertension CHFCHF Previous AMIPrevious AMI

Likely to delay seeking treatmentLikely to delay seeking treatment

Atypical Presentation in Women Discomfort described as:Discomfort described as:

AchingAching TightnessTightness PressurePressure SharpnessSharpness BurningBurning FullnessFullness TinglingTingling

Often have no actual chest pain to offer as a complaint. Often have no actual chest pain to offer as a complaint. Often the pain is in the back, shoulders, or neckOften the pain is in the back, shoulders, or neck

Frequent acute symptoms:Frequent acute symptoms: Shortness of breathShortness of breath WeaknessWeakness Unusual fatigueUnusual fatigue Cold sweatsCold sweats DizzinessDizziness Nausea/vomitingNausea/vomiting

Atypical Presentation in the Patient With Diabetes

Atypical presentation due to autonomic Atypical presentation due to autonomic dysfunctiondysfunction

Common signs/symptoms:Common signs/symptoms: Generalized weaknessGeneralized weakness Generalized feeling of not being wellGeneralized feeling of not being well SyncopeSyncope LightheadednessLightheadedness Change in mental statusChange in mental status

Remember…

Watch out for the “triple threat”Watch out for the “triple threat” How many Elderly women with diabetes How many Elderly women with diabetes

are in your response area?are in your response area?Lots!Lots!

Use of Cardiac SOP’s

Care is initiated for all patients based on Care is initiated for all patients based on your assessmentyour assessment

A pediatric patient is considered under the A pediatric patient is considered under the age of 16 (15 and less)age of 16 (15 and less)

Do not delay care to contact Medical Do not delay care to contact Medical controlcontrol

But, prompt communication is encouragedBut, prompt communication is encouraged

Use of Cardiac SOP’s cont.

Obtaining a history and performing an Obtaining a history and performing an assessment can often provide valuable assessment can often provide valuable informationinformation

Consider underlying causes for all situationsConsider underlying causes for all situations In the cardiac SOP’s, think of the 6 H’s and In the cardiac SOP’s, think of the 6 H’s and

5 T’s as possible causes of the problem as 5 T’s as possible causes of the problem as you progress through assessment & you progress through assessment & treatment for the patienttreatment for the patient

6 H’s HypovolemiaHypovolemia HypoxiaHypoxia Hydrogen ion Hydrogen ion

acidosisacidosis Hyper/hypokalemia Hyper/hypokalemia

(high/low potassium (high/low potassium levels)levels)

HypothermiaHypothermia HypoglycemiaHypoglycemia

Give fluids (20 ml/kg)Give fluids (20 ml/kg) Provide supplemental OProvide supplemental O22

Ventilate to blow off COVentilate to blow off CO22

Difficult to determine in Difficult to determine in the field; consider in the field; consider in diabetic ketoacidosis & diabetic ketoacidosis & renal dialysisrenal dialysis

Attempt rewarmingAttempt rewarming Check blood glucose on all Check blood glucose on all

altered mental status ptsaltered mental status pts

5 T’s Toxins (overdose)Toxins (overdose) Tamponade, cardiacTamponade, cardiac Tension pneumothoraxTension pneumothorax

Thrombosis, coronary Thrombosis, coronary (ACS) or Thrombosis, (ACS) or Thrombosis, pulmonary (embolism)pulmonary (embolism)

TraumaTrauma

Think “out of the box”Think “out of the box” Check for JVD, Check for JVD, B/P B/P Check for JVD, Check for JVD, B/P, B/P,

absent/decreased breath absent/decreased breath sounds, difficulty baggingsounds, difficulty bagging

Obtain 12 lead when Obtain 12 lead when applicable; good history applicable; good history taking to lead to suspicions taking to lead to suspicions (travel, surgery, (travel, surgery, immobility)immobility)

What is history of current What is history of current status?status?

Region X Protocol ACS – Acute Coronary Syndrome (pg. 12)

Assessment for CO Exposure EMS summoned to monitor the air quality for the EMS summoned to monitor the air quality for the

presence of carbon monoxidepresence of carbon monoxide Airborne CO meters are used and documentation made Airborne CO meters are used and documentation made

whether there is a patient transport or notwhether there is a patient transport or not A more immediate concern is the level of CO in A more immediate concern is the level of CO in

the patient’s bloodthe patient’s blood RAD 57 monitors are a non-invasive tool that allows RAD 57 monitors are a non-invasive tool that allows

results in less than 30 secondsresults in less than 30 seconds Rapid diagnosis leads to rapid and appropriate Rapid diagnosis leads to rapid and appropriate

treatmenttreatment

Signs and Symptoms CO Poisoning

Carboxyhemoglobin levels of <15 – 20%Carboxyhemoglobin levels of <15 – 20% Mild severityMild severity

HeadacheHeadacheNausea and vomitingNausea and vomitingDizzinessDizzinessBlurred visionBlurred vision


Carboxyhemoglobin levels of 21 – 40%Carboxyhemoglobin levels of 21 – 40% Moderate severityModerate severity

ConfusionConfusionSyncopeSyncopeChest painChest painDyspneaDyspneaTachycardiaTachycardiaTachypneaTachypneaWeaknessWeakness


Carboxyhemoglobin levels of 41 - 59%Carboxyhemoglobin levels of 41 - 59% Severe Severe

DysrhythmiasDysrhythmias HypotensionHypotension Cardiac ischemiaCardiac ischemia PalpitationsPalpitations Respiratory arrestRespiratory arrest Pulmonary edemaPulmonary edema SeizuresSeizures ComaComa Cardiac arrestCardiac arrest


Carboxyhemoglobin levels of >60%Carboxyhemoglobin levels of >60%FatalFatal

Cherry red skin is not listed as a signCherry red skin is not listed as a sign An unreliable findingAn unreliable finding

Increased Risks Health and activity levels can increase the risk of signs and Health and activity levels can increase the risk of signs and

symptoms at lower concentrations of COsymptoms at lower concentrations of CO InfantsInfants Women who are pregnantWomen who are pregnant

Fetus at greatest risk because fetal hemoglobin has a greater affinity for Fetus at greatest risk because fetal hemoglobin has a greater affinity for oxygen and CO compared to adult hemoglobinoxygen and CO compared to adult hemoglobin

ElderlyElderly Physical conditions that limit the body’s ability to use oxygenPhysical conditions that limit the body’s ability to use oxygen

Emphysema, asthmaEmphysema, asthma Heart diseaseHeart disease

Physical conditions with decreased OPhysical conditions with decreased O22 carrying capacity carrying capacity Anemia – iron-deficiency & sickle cellAnemia – iron-deficiency & sickle cell

Patient Assessment Continuously monitor SpOContinuously monitor SpO22 and SpCO levels and SpCO levels

Remember that SpORemember that SpO22 may be falsely normal may be falsely normal

If you have a CO-oximeter, report the findings to If you have a CO-oximeter, report the findings to

the ED staffthe ED staff Generally, results >3% indicate suspicion for Generally, results >3% indicate suspicion for

CO exposure in non-smokerCO exposure in non-smoker Cardiac monitorCardiac monitor 12 lead EKG obtained and transmitted to ED12 lead EKG obtained and transmitted to ED

Pulse Oximetry

Device to analyze infrared signalsDevice to analyze infrared signals Measures the percentage of oxygenated Measures the percentage of oxygenated

hemoglobin (hemoglobin (saturatedsaturated Hgb) Hgb) Can mistake carboxyhemoglobin for Can mistake carboxyhemoglobin for

oxyhemoglobin and give a false normal level oxyhemoglobin and give a false normal level of oxyhemoglobinof oxyhemoglobin

Never rely just on the pulse oximetry Never rely just on the pulse oximetry reading; always correlate with clinical reading; always correlate with clinical assessmentassessment

Pulse CO-oximeter Device Hand-held deviceHand-held device Attaches to a finger tip similar to pulse ox deviceAttaches to a finger tip similar to pulse ox device Most commonly measured gases in commercial Most commonly measured gases in commercial

devices include devices include Carbon monoxide (SpCO)Carbon monoxide (SpCO) Oxygen (SpOOxygen (SpO22)) Methemoglobin (SpMet)Methemoglobin (SpMet)

Other combustible gasesOther combustible gases Without the device, need to draw a venous Without the device, need to draw a venous

sample of blood to test for CO levelssample of blood to test for CO levels

Pulse CO-oximeter Tool

Firefighters have an increased exposure riskFirefighters have an increased exposure risk Active firefightingActive firefighting Inhaled products of combustion in structure fireInhaled products of combustion in structure fire Inhaled exhaust from vehicles and power toolsInhaled exhaust from vehicles and power tools

Rehab operations more efficient when firefighter Rehab operations more efficient when firefighter can be screened for release back to dutycan be screened for release back to duty Pulse rate, oxygen saturation, carboxyhemoglobin Pulse rate, oxygen saturation, carboxyhemoglobin

levellevel

Treatment CO Poisoning Increasing the concentration of inhaled oxygen Increasing the concentration of inhaled oxygen

can help minimize the binding of CO to can help minimize the binding of CO to hemoglobinhemoglobin

Some CO may be displaced from hemoglobin Some CO may be displaced from hemoglobin when the patient increases their inhaled oxygen when the patient increases their inhaled oxygen concentrationsconcentrations

Treatment begins with high index of suspicion and Treatment begins with high index of suspicion and removal to a safer environmentremoval to a safer environment

Immediately begin 100% OImmediately begin 100% O22 delivery delivery

Treatment CO Poisoning Some guidelines indicate to initiate treatment Some guidelines indicate to initiate treatment

when SpCO levels exceed 10%; some at 12%when SpCO levels exceed 10%; some at 12% Treatment levels vary significantlyTreatment levels vary significantly If you do not have a CO-oximeter to use, maintain a If you do not have a CO-oximeter to use, maintain a

heightened level of suspicion and base treatment on heightened level of suspicion and base treatment on symptomssymptoms

Monitor for complicationsMonitor for complications SeizuresSeizures Cardiac dysrhythmiasCardiac dysrhythmias Cardiac ischemiaCardiac ischemia

CO Poisoning and CPAP

CPAP could assist in fully oxygenating CPAP could assist in fully oxygenating hemoglobinhemoglobin

If considered, call Medical Control for If considered, call Medical Control for permission to use CPAPpermission to use CPAP

Region X Protocol CO Poisoning (pg. 41)

Case #1

45 year-old patient who complains of chest 45 year-old patient who complains of chest heaviness & lightheadednessheaviness & lightheadedness

VS: 90/56; P – 86; R - 22VS: 90/56; P – 86; R - 22 Is there ST elevation:Is there ST elevation:

If so, where?If so, where?

What are you going to do for this patient?What are you going to do for this patient?

Case #1

Case #2 Patient’s spouse called EMSPatient’s spouse called EMS Patient dropping silverware at lunch, unable to sit Patient dropping silverware at lunch, unable to sit

up straight, unable to complete sentencesup straight, unable to complete sentences Vital signs: 170/110; P – 64; R – 16; GCS -14Vital signs: 170/110; P – 64; R – 16; GCS -14 EKG monitor belowEKG monitor below

Case #2 What is your impression?What is your impression? What is the cardiac rhythm?What is the cardiac rhythm?

Atrial fibrillationAtrial fibrillation How does this rhythm relate to any impressions?How does this rhythm relate to any impressions?

What assessments need to be done?What assessments need to be done? Blood sugar level for all patients with altered level Blood sugar level for all patients with altered level

of consciousnessof consciousness Cincinnati stroke scaleCincinnati stroke scale

Case #2 Cincinnati stroke scaleCincinnati stroke scale

Ask the patient to smile real big showing you Ask the patient to smile real big showing you their teeththeir teeth

Ask the patient to put their hands out in front, Ask the patient to put their hands out in front,

palms up, and close their eyespalms up, and close their eyes Hold the position for 10 secondsHold the position for 10 seconds

Ask the patient to repeat a sayingAsk the patient to repeat a saying““You can’t teach an old dog new tricks”You can’t teach an old dog new tricks”

Case #2

What’s the most important question to ask What’s the most important question to ask the patient?the patient?

When did the symptoms begin?When did the symptoms begin?

Case #3

58 year-old male patient who complains of 58 year-old male patient who complains of chest pain radiating down the left arm after chest pain radiating down the left arm after working out in the gymworking out in the gym




Case #3

Case #4

36 year-old patient who passed out standing 36 year-old patient who passed out standing in line at a bankin line at a bank




Case #4

Case #5

Received call from a 10 year-old child that he could Received call from a 10 year-old child that he could not wake up his mother. On arrival the 34 year-old not wake up his mother. On arrival the 34 year-old female was unconscious with signs of seizure female was unconscious with signs of seizure activity. 2 other children are in the home.activity. 2 other children are in the home.

What are your general What are your general impressions/suspicions?impressions/suspicions?

What is included in your assessment?What is included in your assessment? What is your treatment?What is your treatment?

Case #5

Upon scene arrival, a faint odor of exhaust was Upon scene arrival, a faint odor of exhaust was notednoted

Evaluate the patient for normal reasons of altered Evaluate the patient for normal reasons of altered level of consciousness including history of seizure level of consciousness including history of seizure disorder and suicide attemptdisorder and suicide attempt

After 5 minutes on scene, rescue personnel began After 5 minutes on scene, rescue personnel began complaining of headachecomplaining of headache

A car was found running in the garage directly A car was found running in the garage directly under the bedroom/bathroomunder the bedroom/bathroom

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Questions?

Bibliography Various on-line photosVarious on-line photos eHow.comeHow.com Previous CE packetsPrevious CE packets

2006 Condell CE Module2006 Condell CE Module February 2009 Condell CEFebruary 2009 Condell CE February LFFD CE add-on (Jon Bardi)February LFFD CE add-on (Jon Bardi)

CMC SOP pagesCMC SOP pages

cardiac & nervous system emergencies september 2010 ce condell medical center ems system...

Documents

right brain

parts of speech

cerebral blood flowblood

parietal lobe movement

endocrine function

balance brain stem breathing

kidney function

cns cont