2014 Fall Rounds
Agenda
•
•
•
•
•
PCP Manual Defibrillation
Break
Skill station
Break
Anzovino Coroner’s inquest
House Keeping
•
•
•
•
Policy reviews
PPAR – Lectures and Exam
Auxiliary Pain issues
Thou shalt give Benadryl after Epi !
PCP Manual Defibrillation
Learning Objectives
Upon completion of this educational
presentation the paramedic should be able to:
Recognize common VSA ECG rhythms
Identify the benefits of manual defibrillation
Accurately perform manual defibrillation in a
simulated setting
How comfortable are you with the
idea of adult manual defibrillation?
No freakin way man
If I had to I guess…
No problemo
Bring it on!!
gi
to
n!
!
0%
Br
in
le
m
o
0%
pr
ob
to
d
ha
If
I
No
Ig
ue
ss
ay
m
w
fre
ak
in
0%
…
an
0%
No
A.
B.
C.
D.
How comfortable are you with the idea of
pediatric manual defibrillation?
No freakin way man
If I had to I guess…
No problemo
Bring it on!!
gi
to
n!
!
0%
Br
in
le
m
o
0%
pr
ob
to
d
ha
If
I
No
Ig
ue
ss
ay
m
w
fre
ak
in
0%
…
an
0%
No
A.
B.
C.
D.
Let’s start with “WHY?”
• There is published research surrounding the
impact of Peri-Shock pauses on survival to
discharge (Cheskes, et al)
• Less time off the chest = better CPR fractions =
better odds of survival from SCA
• Device interpretation has on some occasions
been inaccurate
Shockable Rhythms
• Pulseless Ventricular Tachycardia (V-Tach)
• Ventricular Fibrillation (V-Fib)
Ventricular Tachycardia (VT)
• Rate: 101-250 beats/min
• Rhythm: regular
• P waves: absent
• PR interval: none
• QRS duration: > 0.12 sec. often difficult to
differentiate between QRS and T wave
Note: Monomorphic - same shape
and amplitude
V-Tach
• 2 Morphologies:
– Monomorphic
– Polymorphic (torsades de pointes)
Shockable Rhythms
• Only 83% of PCP’s could identify the following
rhythm during 2013 fall rounds.
• What is it?
Ventricular Fibrillation (VF)
• Rate: CNO as no discernible complexes
• Rhythm: rapid and chaotic
• P waves: none
• PR interval: none
• QRS duration: none
Note: Fine vs. coarse?
V-Fib
• 2 Morphologies
– Coarse
– Fine
Non-Shockable Rhythms
• Asystole
• Pulseless Electrical Activity (PEA)
Asystole
• Always prudent to verify connections and pad
placement prior to confirming Asystole
Pulseless Electrical Activity (PEA)
• Can look like any rhythm but with no output
Not everyone reads “the book”
Pediatric Defibrillation
• 2 joules per Kilogram followed by 4 joules per
kilogram for all remaining shocks
• Remember weight estimation formula:
– 2 x Age + 10 = ? Kg eg: 2 x 6 yrs + 10 = 22 kg
– ∴ 22 kg X 2 joules per kg = 44 joules
– ∴ 22 kg x 4 joules per kg = 88 joules
• Extremely rare occurrence !
Let’s practice some…
How many years of EMS
experience do you currently have?
25%
Ow
“W
is e
“V
et
er
a
n”
ls”
25%
>1
5
510
“S
ea
s
bi
“N
ew
25%
on
ed
”
e”
25%
10
-1
5
0-5 “Newbie”
5-10 “Seasoned”
10-15 “Veteran”
>15 “Wise Owls”
05
A.
B.
C.
D.
If your patient is 3 years old, how
much would you estimate his/her
weight to be?
6 kg
9 kg
16 kg
14 kg
27%
kg
14
kg
20%
16
kg
9
kg
20%
6
A.
B.
C.
D.
33%
What would be the first joules setting
to defibrillate this patient?
32 joules
64 joules
16 joules
120 joules
30%
23%
jo
ul
es
12
0
jo
ul
es
16
jo
ul
es
64
jo
ul
es
17%
32
A.
B.
C.
D.
30%
What would be all of the following
joules settings to defibrillate this
patient?
32 joules
64 joules
16 joules
120 joules
27%
27%
27%
jo
ul
es
12
0
jo
ul
es
16
jo
ul
es
64
jo
ul
es
20%
32
A.
B.
C.
D.
If your patient is 5 years old, how
much would you estimate his/her
weight to be?
10 kg
15 kg
20 kg
30 kg
27%
23%
kg
30
kg
20
kg
15
kg
13%
10
A.
B.
C.
D.
37%
What would be the first joules setting
to defibrillate this patient?
10 joules
40 joules
20 joules
100 joules
17%
jo
ul
es
10
0
jo
ul
es
20
jo
ul
es
10%
40
jo
ul
es
13%
10
A.
B.
C.
D.
60%
What would be the remaining joules
settings to defibrillate this patient?
23%
jo
ul
es
40
jo
ul
es
80
jo
ul
es
17%
jo
ul
es
20%
20
100 joules
80 joules
40 joules
20 joules
10
0
A.
B.
C.
D.
40%
Shock or No Shock?
60%
No
Sh
o
ck
40%
Sh
oc
k
A. Shock
B. No Shock
V-Fib with pacemaker spikes
Select the Non Shockable Ryhthm
A.
33%
27%
B.
23%
17%
C.
h
ac
VT
PE
A
VFib
e
Fin
Co
u
rs
e
V-
Fib
D.
Team Scores
Points
Team
Points
Team
What percentage of your current
points would you like to wager on
the next question?
A.
B.
C.
D.
E.
0%
25%
50%
75%
100%
Shocking asystole is of no benefit to
the patient?
Tr
50%
se
ue
50%
Fa
l
A. True
B. False
Enter Question Text
63%
37%
sh
oc
k
No
Sh
oc
k
A. Shock
B. No shock
Enter Question Text
50%
50%
ab
l
oc
k
Sh
No
n
Sh
oc
ka
bl
e
e
A. Shockable
B. Non Shockable
Enter Question Text
73%
A. Shockable
B. Non Shockable
ab
l
oc
k
Sh
No
n
Sh
oc
ka
bl
e
e
27%
Enter Question Text
50%
50%
ab
l
oc
k
Sh
No
n
Sh
oc
ka
bl
e
e
A. Shockable
B. Non Shockable
Enter Question Text
53%
47%
ab
l
oc
k
Sh
No
n
Sh
oc
ka
bl
e
e
A. Shockable
B. Non Shockable
Enter Question Text
63%
37%
ab
l
oc
k
Sh
No
n
Sh
oc
ka
bl
e
e
A. Shockable
B. Non Shockable
Enter Question Text
53%
47%
ab
l
oc
k
Sh
No
n
Sh
oc
ka
bl
e
e
A. Shockable
B. Non Shockable
Enter Question Text
57%
43%
ab
l
oc
k
Sh
No
n
Sh
oc
ka
bl
e
e
A. Shockable
B. Non Shockable
What percentage of your current
points would you like to wager on
the next question?
A.
B.
C.
D.
E.
0%
25%
50%
75%
100%
When in doubt about the rhythm just
shock it?
Tr
50%
se
ue
50%
Fa
l
A. True
B. False
Team Scores
Points
Team
Points
Team
How to….
Physio Control LP 15
How to?
• Confirm desired energy is selected, or
press ENERGY SELECT
Or….
• Rotate the SPEED DIAL to select the
desired energy.
How to?
• Press CHARGE. While the defibrillator is
charging, a charging bar appears and a ramping
tone
• sounds, indicating the charging energy level.
When the defibrillator is fully charged, the
screen
• displays available energy.
• Press the
(shock) button on the defibrillator
Safety first
• To disarm (cancel the charge), press the SPEED
DIAL.
• The defibrillator disarms automatically if
shock buttons are not pressed within 60
seconds, or if you change the energy selection
after charging begins.
Easy as 1-2-3?
1
2
3
Event Marking
• Use the Events menu to annotate Manual
Analysis
• When selected, event appears in the “Event
Log” of the CODE SUMMARY critical event
record.
To select an event:
1. Press EVENT to display the Events menu.
2. Rotate the SPEED DIAL to scroll through the
choices. Press the SPEED DIAL to make a
selection.
3. Select MORE to display additional event
selections.
4. EMS operators will be responsible for Event
key programming
Pediatric Attenuators
• Services may elect to keep Pediatric
attenuation capabilities until they expire
IMPORTANT !!!
• If using Pediatric attenuator pads, do not use
the 2 J/kg or 4 J/kg calculation
Now how comfortable are you with the
idea of adult manual defibrillation?
No freakin way man
If I had to I guess
No problemo
Bring it on!!
in
gi
to
n!
!
0%
Br
bl
em
o
0%
pr
o
to
ha
d
If
I
No
Ig
m
an
ay
w
fre
ak
in
0%
ue
ss
0%
No
A.
B.
C.
D.
Now how comfortable are you with the
idea of pediatric manual defibrillation?
No freakin way man
If I had to I guess
No problemo
Bring it on!!
in
gi
to
n!
!
0%
Br
bl
em
o
0%
pr
o
to
ha
d
If
I
No
Ig
m
an
ay
w
fre
ak
in
0%
ue
ss
0%
No
A.
B.
C.
D.
Now how comfortable are you with the idea of
adult manual defibrillation?
100
No freakin ...
100
100
If I had to...
100
100
No problemo
100
100
Bring it on!!
100
First Slide
Second Slide
Now how comfortable are you with the idea of
pediatric manual defibrillation?
100
No freakin ...
100
100
If I had to...
100
100
No problemo
100
100
Bring it on!!
100
First Slide
Second Slide
Break
Case Study
Anzovino Coroner’s Case Verdict
First a quick survey; True or False there is
such a thing as a “Load and Go Patients”
standard within the BLS PCS ?
A. True
B. False
se
0%
Fa
l
Tr
ue
0%
The story
• On December 26th, 2009 18 year old Reilly
Anzovino had been out shopping with a friend
and in the evening, went to a party at a
residence in Fort Erie.
• It was a typical December day with normal
temperature for the time of year.
• Later that evening, the temperature dropped
precipitously resulting in a thick fog and icy
road conditions
The story
• Ms. Anzovino departed the gathering in a car
driven by her friend and she was the front
seat passenger travelling westbound on Hwy 3
toward Port Colborne.
• Salt trucks had been mobilized by the
municipality but they had just begun salting
the easterly stretch of the Hwy.
West
The story
• At around 23:30 hrs, the car carrying Ms.
Anzovino approached an embanked “S” turn
in the road and encountered significant black
ice.
• The driver lost control, the vehicle spun
several times, crossed into the eastbound lane
and was struck broad side by a car on the
front passenger door.
The story
• Several vehicles approached the scene and a
second minor accident occurred involving 2
other separate vehicles.
• Several 911 calls are received
• EMS, Police and Fire are dispatched
The call
• You are dispatched priority 4 to an MVC in the
eastbound lane of a local Hwy.
• Road conditions are “icy”
• You are the first crew on scene.
The Scene
What is your first course of
action?
Ensure scene safety
Initiate MCI triage
Obtain incident history
Call for backup
Ca
l
lf
or
ba
c
ist
en
th
in
c id
in
0%
or
y
ge
tri
a
CI
M
Ob
ta
te
tia
In
i
sc
en
e
0%
ku
p
0%
sa
fe
ty
0%
En
su
re
A.
B.
C.
D.
The call
• Your patient is an 18 year old restrained front
passenger of a vehicle that was struck directly
on the front passenger side.
• CACC advises Ornge is not available due to
weather
What is your first course of
action?
0%
0%
Ke
nd
r
Lo
ick
ad
&
Ex
...
Go
0%
Pr
ep
a
re
th
e
te
tia
As
se
ss
L
OC
,B
,C
’s
(A
VP
U)
0%
In
i
Assess A,B,C’s
Assess LOC (AVPU)
Initiate Load & Go
Prepare the Kendrick
Extrication Device (KED)
As
se
ss
A
A.
B.
C.
D.
The call
• Your patient is unconscious upon contact but
is breathing and has a pulse.
• Extrication is not possible from the passenger
side due to extent of damage
Who would?
fu
l
nd
py
a
th
er
a
O2
0%
..
as
se
..
an
d
tia
Fu
l
ly
im
m
ob
ili
e
ze
pa
t
0%
te
tio
ca
ly
ex
tri
ca
t
fo
re
xt
ri
Ra
pi
d
fo
rF
D
ait
W
0%
ie
nt
...
n
0%
In
i
A. Wait for FD for
extrication
B. Rapidly extricate patient
with C-Spine
precautions through
driver side
C. Fully immobilize and
assess vitals in position
found
D. Initiate O2 therapy and
fully assess the patient
The call
• The patient is extricated and fully immobilized
• You “wheel” her to your Ambulance on your
stretcher where she becomes conscious and
combative
What is your next course of
action?
e.
..
0%
ai
n
th
e
pa
t
ie
nt
’s
fv
it a
ls
0%
he
rs
et
o
an
ot
in
As
se
ss
glu
co
m
et
ry
0%
Ob
ta
In
i
tia
te
ra
pi
d
tra
ns
po
r
t.
.
0%
Re
st
r
A. Initiate rapid
transport to the ED
B. Assess glucometry
C. Obtain another set
of vitals
D. Restrain the
patient’s extremities
for safety
The patient
• Patient has multiple obvious injuries to her Rt
side (poss # arm, femur and tib-fib)
• Large laceration to her Rt frontal/temporal
head
• Vitals – GCS of 9, HR 130 weak, reg, BP 88/50,
skin is pale, cool and dry. Resp 28 reg and full.
• Pupils not assessed
An ACP arrives/As a PCP IV, what
should their/your next course of
action be?
0%
to
ll.
..
ea
iliz
re
ce
iv
At
te
m
pt
th
e
im
m
ob
in
gf
ac
. ..
rg
e
la
le
rt
Pr
ea
0%
.. .
0%
2
ce
ss
(
ac
IV
in
Ob
ta
tia
te
ra
pi
d
tra
ns
po
r
tt
. ..
0%
In
i
A. Initiate rapid
transport to the ED
B. Obtain IV access (2
large bore)
C. Pre-alert the
receiving facility
D. Attempt to
immobilize all
suspected fractures
The patient
• Several individuals keep interrupting the
Paramedics while on scene.
• Time is taken to start an IV prior to leaving the
scene.
• They depart the scene at 00:07 hrs.
• En route, the patient becomes increasingly
tachycardic and as the Paramedics approach
the hospital, the patient becomes VSA.
What is your next course of
action? (Hospital in sight)
A. Initiate CPR, secure
the airway with King
LT or ETT
B. Initiate CPR, pull over
and perform 1
analysis
C. Initiate CPR and
continue to the ED
D. Patch to the BHP for
further orders
te
tia
In
i
0%
0%
0%
CP
R,
se
cu
In
re
iti
at
th
eC
e
a.
PR
..
,p
u
ll
In
ov
iti
at
er
eC
an
PR
...
an
d
Pa
co
tc
nt
h
in
to
ue
th
..
eB
HP
fo
rf
ur
th
..
0%
Arrival at the ED
• Patient brought to the Trauma room – VSA at
00:29 hrs.
• Full resuscitation is performed.
• Blood noted in the urine and the abdomen
was markedly distended.
• Patient was pronounced at 01:21 hrs.
Some pertinent details
• Extrication was challenging due to icy road
conditions and was accomplished via the
driver side.
• Transport time was 22 minutes.
• Extrication Inside the ambulance, the patient
was restrained (4 points).
• The attending Paramedic attempted
intubation when the patient went VSA –
unsuccessful.
Some pertinent details
• The emergency rooms at Douglas Memorial
(Fort Erie) and Port Colborne General
Hospitals had been closed several months
earlier as part of a controversial restructuring
plan by the Niagara Health System.
Why a coroner’s inquest?
• Cause of death:
– Blunt Force Trauma due to a MVC
• The inquest was called at the discretion of the
coroner’s for the following factors:
– The pre-hospital care provided including scene
and transport times
– Whether the conversion of EDs in Fort Erie and
Port Colborne to Urgent Care Centre’s was a factor
in the patient’s death.
Welland County
General Hospital
MVC
UCC
UCC
The Verdict
• 27 recommendations to all stakeholders
• # 21 states that the Jury recommends that this
case be used as an educational example for
base hospitals and all paramedic training in
Ontario.
The Verdict
• #25 the jury encourages the MoHLTC to
review the training and/or standards provided
to paramedics concerning the “Load and Go
Patient Standard” set out in the BLS PCS. The
review should ensure that the training and
standards rely on evidence-based medicine.
Any required interventions should be
attempted en route to hospital, and should
not delay departure from scene.
The evidence
• An analysis of prehospital deaths: Who
can we save?
– Davis et al, Journal of Trauma Acute Care and
Surgery, August 2014
– Look at causes of prehospital trauma deaths
– 512 patients included and most died of either
blunt (53%) or penetrating causes (46%)
The evidence
• An analysis of prehospital deaths: Who can
we save?
– 29% (approx. 150 patients) of deaths were
classified as “potentially survivable” injuries given
current treatment options
– The “preventable” deaths were mostly from
hemorrhages and chest injuries suggesting
prehospital scene times impact trauma survival
The evidence
• The impact of injury severity and prehospital
procedures on scene time in victims of major
trauma.
– Spaite, et al 1991
– Looked at 98 patients transported by Paramedics
to a “Trauma Centre”
– Looked at scene times, procedures and injury
severity scores
– The more injured the patients were…the more
time
The evidence
• The impact of injury severity and prehospital
procedures on scene time in victims of major
trauma.
– The more injured the patients were…the more
procedures were performed on scene
– Despite this, scene times were shorter for the
more severely injured patients
– Mean scene time for this study was 8.1 minutes!
The evidence
• The impact of injury severity and prehospital
procedures on scene time in victims of major
trauma.
– Conclusion: scene times can be kept short
regardless of the injury severity without
foregoing potentially life saving treatments
The evidence
• The OPALS Major Trauma Study: impact of
advanced life-support on survival and
morbidity.
– Stiel, et al 2008
– 2867 patients enrolled
– Looked at ALS vs BLS in major traumas
– Conclusion: system wide implementation of an
advance life support program did not impact
mortality and morbidity in major trauma patients.
Summary
• People survive major traumas
• LOAD & GO ASAP !
• Do what you have to do enroute
Quiz
If your patient is 4 years old, how
much would you estimate his/her
weight to be?
kg
25%
18
kg
25%
16
kg
25%
9
kg
6 kg
9 kg
16 kg
18 kg
6
A.
B.
C.
D.
25%
What would be the first joules setting
to defibrillate this patient?
jo
u
le
s
25%
12
0
jo
ul
es
25%
36
jo
ul
es
25%
64
jo
ul
es
32 joules
64 joules
36 joules
120 joules
32
A.
B.
C.
D.
25%
What would be the remaining joules
settings to defibrillate this patient?
jo
ul
es
25%
20
jo
ul
es
25%
40
jo
ul
es
25%
72
jo
u
le
s
100 joules
72 joules
40 joules
20 joules
10
0
A.
B.
C.
D.
25%
If your patient is 7 years old, how
much would you estimate his/her
weight to be?
kg
25%
24
kg
25%
16
kg
25%
10
kg
14 kg
10 kg
16 kg
24 kg
14
A.
B.
C.
D.
25%
What would be the first joules setting
to defibrillate this patient?
jo
u
le
s
25%
12
0
jo
ul
es
25%
16
jo
ul
es
25%
64
jo
ul
es
48 joules
64 joules
16 joules
120 joules
48
A.
B.
C.
D.
25%
What would be the remaining joules
settings to defibrillate this patient?
jo
ul
es
25%
20
jo
ul
es
25%
80
jo
ul
es
25%
96
jo
u
le
s
100 joules
96 joules
80 joules
20 joules
10
0
A.
B.
C.
D.
25%
25%
25%
A
V-Fib
V-Tach
Asystole
PEA
b
A.
B.
C.
D.
25%
e
25%
h
Please identify the following
rhythm:
25%
25%
A
V-Fib
V-Tach
Asystole
PEA
b
A.
B.
C.
D.
25%
e
25%
h
Please identify the following
rhythm:
25%
25%
st
As
y
VTa
ch
V-Fib
V-Tach
Asystole
PEA
VFi
b
A.
B.
C.
D.
25%
PE
A
25%
ol
e
Please identify the following
rhythm:
25%
25%
st
As
y
VTa
ch
V-Fib
V-Tach
Asystole
PEA
VFi
b
A.
B.
C.
D.
25%
PE
A
25%
ol
e
Please identify the following
rhythm: (Patient is VSA)
Thank you !