CARDIAC EMERGENCY 114 Post Resuscitation Assessment Completion of arrhythmia treatment Oxygen 100% and airway maintenance appropriate to the patient’s condition Supportive care EMT STOP IV NS TKO Assess BP – If systolic <90 mmHg administer 250 ml NS (peds systolic BP 70 + 2x age, 20 cc/kg bolus) repeat until BP >90 mmHg or appropriate for pediatric age. Check blood sugar, if low titrate dextrose 50% prn slowly until normal levels achieved. Try to avoid large swings in serum glucose levels (peds – see glucose dosing chart) Raise head of bed 30° AEMT STOP 12 Lead EKG, transmit Ensure head of bed is raised 30° Medications: If anti-arrhythmic administered: Amiodarone – 300mg IV (peds 5 mg/kg , may repeat x 2), if one dose given and arrhythmia persists, give second dose 150 mg If Lidocaine administered, start infusion drip at 2-4 mg/min (peds – 20-50 mcg/kg/min) Continue ventilatory support to maintain Respirations <12 ideally (peds – infant-preschool min respiratory rate should be 30. school age – min respiratory rate should be 20) Initiate Induced Hypothermia protocol if appropriate Treatment - Protocol If patient does not tolerate ET tube, contact Medical Control for: Valium 2-10 mg (peds 0.1 mg/kg) or Versed 2-5 mg IV (peds 0.1 mg/kg) for patient sedation. Note: Use soft restraints if necessary for patient safety (to prevent extubation)
REFERENCE Mini Mental Status Exam Orientation to time – time of day, day, week, month, year 5 pts max Orientation to place – building, street, city, state, country 5 pts max Say “boy, dog, ball” and have the patient repeat it 3 pts max Ask the patient to spell would backward, or do serial 3s backward from 20 5 pts max Without repeating the ask them to repeat the previous three words (boy, dog, ball) 3 pts max Ask the patient to do the following after you have completed the request “stick out your tongue and touch your right hand to your left ear” 3 pts max Ask the patient to identify your pen and watch 2 pts max Ask the patient to read the following sentence then do as it says “Shut your eyes” 1 pt Ask the patient to write a sentence 1 pt Ask the patient to draw two overlapping pentagons (show them an example) 1 pt A score of 21 or better is considered mentally competent by most psychiatrists for a patient to make reasonable decisions.
REFERENCE Quality Improvement Document Criteria Documentation on all patients must include the following and any other information pertinent to patient care: OPQRST and SAMPLE are the acronyms for the United States DOT EMS and Paramedic patient assessment curriculum O – Circumstance surroundings on the onset of complaint P – What provoked (or provokes) the complaint? Environment Q – Describe the quality (sharp, burning, stabbing counter etc.)of the complaint? R – does the pain radiate? S – Describe the severity of the pain on a 1-10 scale 1 (minimal) – 10 (maximum) T – Time of onset? S – Signs, symptoms, physical exam findings A – Allergies to medications or the environment M – Medications, prescription or over the counter P – Past medical history L – Last oral intake E – Event, what happened to the patient All patients transported by EMS should have at two sets of vital signs assessed and documented. Initial set of vitals will include blood pressure (systolic/diastolic), pulse rate, respiratory rate, pulse oximetry and blood glucose if indicated, and the time they were assessed must be recorded. All medications taken by the patient should be listed on the report. If medications are taken to ER document in narrative who the medications were left with. When documenting the presumed presence of alcohol that is based solely upon breath odor, do so in the following manner: “Patient’s breath has the odor that is commonly associated with the consumption of alcohol.” ABDOMINAL PAIN/PROBLEMS Location of pain Distension Tenderness/radiation Nausea/Vomiting/Diarrhea Urinary complaints LMP if applicable Vaginal bleeding/discharge if applicable Treatment/reassessments Report and signature of RN ALCOHOL INTOXICATION Patient’s breath has odor of ETOH Patient admits to drinking (type, amount, time frame) Speech (normal, slurred) Gait (normal, unsteady) Any obvious injuries Blood glucose level of consciousness Treatment/reassessments Report given and signature of RN ALTERED MENTAL STATUS OPQRST, SAMPLE as appropriate ETOH/Substance use Any obvious injuries noted Blood glucose level Normal mental status EKG and strip attached Treatment/reassessments Report given and signature of RN ASSAULT/FIGHT OPQRST, SAMPLE as appropriate Method of assault Any obvious injuries or pain Loss of consciousness, how long Treatment/reassessments Report given and signature of RN
AIRWAY OBSTRUCTION Can patient speak/forcibly cough Is patient moving air Inspiratory stridor What caused obstruction Duration of obstruction Treatment/reassessments Report given and signature of RN ALLERGIC REACTION of reaction Dyspnea Facial/airway edema Chest pain Rash/Itching Urticaria/Hives Treatment/reassessments Report given and signature of RN ANIMAL BITE/STING Type of animal or insect Location of Edema at site Rabies/immunization status of animal if appropriate Treatment/reassessments Report given and signature of RN ATRAUMATIC GI Nausea, vomiting, diarrhea, constipation Active bleeding Bloody emesis/stool, how long? Abdominal pain, location and quality Treatment/reassessments Report and signature of RN BURN Burn source chemical, electricity) Environment (enclosed, outside) Entrance/exit wounds if appropriate Burn surface area and thickness Facial, oral, nasal areas singed pain/dyspnea Treatment/reassessments Consider Cyanide Antidote Report given and signature of RN CARDIAC ARREST Events prior to onset Description/location of patient on arrival Estimated down time Treatment/reassessments Report given and signature of RN PAIN OPQRST and SAMPLE as appropriate Factors relieving or increasing pain Dyspnea, cough Nausea, vomiting Diaphoresis Aspirin within past 12 hours Treatments/reassessments Report and signature of RN CHF/PULMONARY EDEMA/SOB Chest pain Dyspnea Nausea, vomiting Diaphoresis JVD/lower extremity edema Treatments/reassessments Report given and signature of RN DEATH Last time patients seen or talked to Position/Location of body Any movement of body made by EMS Any injuries Dependent lividity/ rigor mortis EKG strip in two leads attached Released to DIABETIC OPQRST and SAMPLE as appropriate Nausea/vomiting/recent illness Pre/Post treatment of blood glucose level Treatment/reassessments Report given and signature of RN HYPERTENSION HYPER/HYPOTHERMIA
Chest pain/dyspnea Nausea/vomiting Headache/mental status Assessment Treatments/Reassessments Report given and signature of RN Approximate ambient air temperature Estimate exposure time Type of environment (inside, outside, wet) Loss of consciousness Fluid intake Skin turgor/condition ETOH/Substance Treatments/reassessments Report given and signature of RN INHALATION INJURY (TOXIC GAS/SMOKE) Type of gas Duration of exposure Area of exposure (enclosed room) Heated environment (oral, nasal, facial area) Treatments/reassessments Report and signature of RN POISONING/DRUG INGESTION Name of substance Amount Route of intake How long ago Vomiting since ingestion as appropriate Intentional vs. Unintentional ETOH/substance use Oral mucosa burns if appropriate Treatments/reassessments Report given and signature of RN PREGNANCY/OB DELIVERY Separate report required for mother and each delivery Non-Delivery Abdominal Pain Gravida/Para/Abortion Length of gestation/estimated due date Edema (pedal)/BP/Headache/Visual Disturbance Vaginal bleeding/discharge – if yes, describe Treatments/reassessments Report given and signature of RN Last time fetal movement REFUSALS Documentation of: Competency MMSE Lack of Trauma Situation Ability to make good decisions Safety of patient is assured by caretakers, family, etc Delivery Multiple fetuses Mucous plug resented Membranes ruptured – if yes, is amniotic fluid clear? Crowning as appropriate SEIZURES OPQRST and SAMPLE as appropriate Obvious injures head, tongue) Duration and number of events Incontinence of consciousness (postictal) Treatments/reassessments Report given and signature of RN NEONATE Time of birth Thoroughly dried and warmed Oral and suctioning STROKE/CVA/TIA OPQRST and SAMPLE as appropriate Onset and duration of symptoms Headache/Vision disturbances
Meconium present APGAR at 1 and 5 minutes General appearance Treatments/Reassessments Report and signature of RN Thrombolytic screening and stroke screen Treatments/Reassessments Report given and signature of RN SYNCOPE/FAINTING/WEAKNESS OPQRST and SAMPLE as appropriate Injuries, chest pain, dyspnea, nausea Vertigo/postural/TILT changes New or changed medications Last meal Blood glucose level EKG ETOH/Substance use Treatments/Reassessments Report given and signature of RN TRAUMA OPQRST and SAMPLE as appropriate Description of Weapon (size, caliber, depth of penetration) if applicable Description of damage, estimated speed, airbag deployment as applicable Patient protection as applicable Tourniquet use Level of or Loss of consciousness Obvious injuries and area of pain Palpation/assessment of injured areas Disability (PMS/SMC intact) Treatments/reassessments Report given and signature of RN
REFERENCE Common Medical Abbreviations a = before AED = Automated External Defibrillator AOX3 = alert and oriented to person place and time Abd = Abdomen Ab. = Abortion ac = antecubital AF = atrial fibrillation ARDS = Adult Respiratory Distress Syndrome AT = atrial tachycardia AV = atrioventricular b.i.d. = a day BSA = Body Surface Area BS = sugar and/or Breath Sounds c = with CC or C/C = Chief Complaint CHF = Congestive Heart Failure CNS = Central Nervous System c/o = complains of CO = Carbon Monoxide CO2 = Carbon Dioxide D/C = discontinue DM = diabetes mellitus DTs = delirium tremens DVT = deep venous thrombosis Dx = Diagnosis ECG/EKG = electrocardiogram EDC = estimated date of confinement EJ = external jugular ENT = ear, nose, and throat ETOH = the abbreviation of Ethanol (grain alcohol) fl = fluid fx = fracture GB = gall bladder Gm/g = gram gr. = grain GSW = Gunshot Wound gtt. = drop GU = genitourinary GYN = gynecologic h/hr = hour H/A = headache Hg = mercury H&P = History and Physical Hx = history ICP = intracranial pressure JVD = jugular venous distension KVO = keep vein open LAC = laceration LBBB = left bundle branch block MAEW = moves all extremities well NaCl = sodium chloride NAD = No apparent distress/no acute distress NPO = Nothing by mouth NKA = No known allergies OD = overdose O.D. = right eye O.S. = left eye PERL = pupils equal and reactive to light PID = pelvic inflammatory disease p.o. = by mouth 1° = primary, first degree PTA = prior to arrival pt. = patient q = every q.h. = every hour q.i.d. = four times a day RBBB = right bundle branch block R/O = rule out ROM = range of motion Rx = take, treatment s = without S/S = signs and symptoms TIA = transient ischemic attack t.i.d. = three times a day V.S. = signs y.o. = years old
REFERENCE – PEDIATRIC Age, Weight, and Vitals Chart Age Weight (kg) Normal Diastolic BP Normal Systolic BP Heart Rate Per Minute Respiratory Rate Per Minute Birth 3.5 56 – 70 66 – 90 110 – 160 30 – 60 6 mons 7.0 56 – 70 70 – 104 100 – 140 30 – 50 1 year 10.0 56 – 76 80 – 104 100 – 140 24 – 34 2 years 13.0 56 – 76 80 – 104 90 – 110 20 – 30 3 years 15.0 56 – 76 80 – 104 90 – 110 20 – 30 4 years 17.0 56 – 76 90 – 110 80 – 110 20 – 30 5 19.0 56 – 76 90 – 110 80 – 110 20 – 30 6 23.0 56 – 76 90 – 110 70 – 100 16 – 30 7 years 25.0 56 – 76 90 – 110 70 – 100 16 – 30 8 years 28.0 60 – 76 90 – 110 70 – 100 16 – 30 9-10 years 30.0 64 – 76 90 – 114 70 – 90 10 – 20 11-12 years 37.0 64 – 80 90 – 120 70 – 90 10 – 20 13-15 years 50.0 64 – 80 110 – 124 60 – 80 10 – 20 16-18 65.0 64 – 90 110 – 134 60 – 80 10 – 20 Size ETT = 16 + (age in years) 4 REFERENCE – PEDIATRIC Age and Weight Related Pediatric Equipment Guidelines Premature 3 kg Newborn 3.5 kg 6 Months 7 kg 1 – 2 years 10 – 12 kg 5 years 16 – 18 kg 8 – 10 25 – 36 kg C – Collars Small Small Small Medium O2 Masks Premature or Newborn Newborn Pediatric Pediatric Pediatric Adult BVM Infant Infant Pediatric Pediatric Pediatric Pediatric or Adult Laryngoscopes 0 1 1 1 2 2 – 3 ET Tubes 2.5 – 3.0 3.0 – 3.5 3.5 – 4.5 4.0 – 4.5 5.0 – 5.5 5.5 – 6.5 Suction Catheters 6 – 8 Fr 8 Fr 8 – 10 Fr 10 Fr 14 Fr 14 Fr Oral Airways Infant Infant or Small Small Medium Medium or IV Equipment 22 – 24 22 – 24 angio 22 – 24 angio 20 – 22 angio 20 – 22 angio 20 – 22 BP Newborn Newborn Infant or Child Child Child or Adult