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Written & Illustrated by: John A.

Watson V, CCEMT-P, NC Level I EMS Instructor, Training Officer, MEDIC

CCEMT-P Notes Day #1


Concepts & Components
Ideal Critical Care Team composition variation of Medic, RN, RT, MD Standard of care An agreed upon level of excellence Transport protocols and procedures must be clearly written in advance Critical Care medicine is a totally separate subset from pre-hospital EMS History of Ambulance transports: o Paramedic Inception Miami Fire Department (1970) o First Air Transport Prussian Siege (1870) Hot Air Balloons o First Helicopters Korean Conflict (1950) Modes of Transport: o Mobile (0-50 miles) o Rotor Wing (10-150 miles) o Fixed Wing (150 miles or more)

Medical Legal
* www.pwwemslaw.com *

CCEMT-P scope of practice - governed by civil laws (statutes), rules & regulations in each state Appropriate Care: Duty, Breach, Damages, Proximate Cause When patient info can be released Continuation of care, law requires it, billing, subpoena Pertinent transfer info Reason for transfer, MD to MD contact required PTA, treatment of patient, treatment and orders within your scope of practice, report: CC, S/S, Assessment, H&P, Plan of Care EMTALA (Emergency Medical Treatment & Active Labor Act) Requirements: Medical Records, S/S, Diagnosis, Test Results, Written Consent, MD verification that risks of transport outweigh the benefits Review Case Law for Exam

NG/ OG/ Ostomies


-Rectal Considerations Small amount of blood on stool Hemorrhoids Small amount of blood in stool Lower GI Hemorrhage Melena (digested blood) Upper GI Hemorrhage Decubitus Ulcers: o Decubiti Stage I redness not removed by elimination of pressure o Decubiti Stage II lesions involving excoriation o Decubiti Stage III full thickness skin loss o Decubiti Stage IV ulcers with invasion of fascia, connective tissue, muscle or bone

-Ostomies-

Stoma opening in the abdominal wall where the end of the colon is brought to the skin surface Indications: o Bowel Injury/ Disease o Bladder Injury/ Disease o Decompression o Stool Diversion Most common ostomy - Colostomy Diversion of urine from the bladder Urostomy Ureterostomies located on the patients flank -Renal Assessment & Urinary Catheters-

Indications: o Incontinence o Sedated/ Paralyzed Patients o Inability to void o Collection of Specimen Nephrolithiasis (Kidney Stones) - Types: Calcium, Struvite, Uric Acid, Cystine Urinary Tract Infections More common in females, E. Coli in 80% of patients Normal Urine Output: 30+ ccs per hour Order of Assessment: Visualization, Auscultation, Palpation, Percussion -Nasogastric, Orogastric & Feeding Tubes-

Gastric Tube contraindications esophageal varices, head injury or facial trauma (NG Tube) NG/OG Indications: Eternal Feeding, Medication Administration, Gastric Lavage & Decompression Measure NG/ OG tube from tip of nose to earlobe to xiphoid process Percutaneous Endoscopic Gastrostomy/ Jejunostomy (PEG/ PEJ) tube Feeding Tube

CCEMT-P Notes Day #2


Therapeutic Hypothermia (Not to be tested on)
Less than 5% of cardiac arrest patients will be resuscitated With successful resuscitation, hypothermia should be initiated within 15 minutes History of Therapeutic Hypothermia o (1814) Invasion of Russia o (1930) Germany experimented in prison camps o (1970-1990) Benefits proven, skeptics still prevailed o (2001-2002) Widely studied & benefits clearly demonstrated Why cool? Help save brain tissue When to cool? Immediately after return of spontaneous circulation Who to cool? At least 16 years old How to cool? Preferably Cool IV Saline Goal is to drop core temperature to 93 degrees Hypothermia reduces metabolic demand by 50% Patient can develop metabolic alkalosis with cooling. DO NOT hyperventilate!

X-Ray Interpretation
If you see upper rib fractures, always assume c-spine injury Diaphragm is dome-shaped with clear costophrenic angles (inferior bilaterally) Inferior Ventricular Width is approximately 1/3 to1/2 the chest width Air = Black Fresh blood & water = Opaque White Tissue = Dense White ET Tube - should be 2cm above the carina Consolidation Infection, fluid, inflammatory exudate Atelectasis No ventilation to the lobe beyond obstruction (leads to pneumonia) Order of Chest X-Ray assessment: o A Airway (midline?) o B Bone Structures (visible?) {asymmetry, fractures, lesions, curvature of spine } o C Cardiac (size?) o D Diaphragm (clear costophrenic angles?) o E Event (Chronic or Acute?) 5 Steps to X-Ray Interpretation: 1. Assess lung expansion 2. Assess pleura 3. Look for infiltrates 4. Look at the mediastinum 5. Assess the abdomen Infiltrate = Pneumonia Thumb print/ Thumb sign = epiglottitis Steeple Sign = Croup Increased prominence in pulmonary vasculature, cardiomegaly = heart failure Diaphragm Right side is always higher 'White out consolidation or fluid filled alveoli Fluffy Pneumonia or ARDS Cor = size of the heart

CT Scan assessment & findings: o The X Look for symmetry in the film o Black spots Infarct or old blood o White spots Acute blood o Ventriloquist Are the ventricles compressed or too large? o Breaks Are there any fractures? o Masses Are they new or old?

Multi-System Organ Failure


Clinical Setup of MSOF (Multi-System Organ Failure) o MSOF: A group of conditions which results in varied physiological dysfunction of more than two organs: Sepsis, ARDS, DIC o Sepsis/ Septic Shock Infection with failure of at least one organ Misdistribution of blood (under-perfused & over-perfused areas) Caused by Microorganism invasion (aerobes, anaerobes, fungi, viruses) Bacteremia Microorganisms/ toxins in the blood Etiology: Gram (-) Endotoxin (E. Coli) {Released when bacterium broken} Gram (+) Exotoxin History: DM HTN CHF COPD Cirrhosis HIV CX Pregnancy Signs & Symptoms: Tachycardia Fever/ Hypothermia Tachypnea Hypo-perfusion Management: Fluid Therapy (preferably colloids) 20 ml/kg Vasopressors & (+) Inotropes Antibiotics Corticosteroids

ARDS (Acute Respiratory Distress Syndrome) relative pulmonary failure, characterized by hypoxemia with shunting, dyspnea and onset of bilateral diffuse pulmonary infiltrates on x-ray Usually develops within 24 - 48 hours of the insult Etiology: MSOF Insult to the lung Pneumonia Chest Trauma Burns Near Drowning Pancreatitis Signs & Symptoms: Dyspnea, Rapid & Shallow Respirations Accessory muscle use Cyanotic or mottled skin, not improving with O2 Management High FiO2, ABGs, Ventilation, CPAP c PEEP, fluid administration End Result - Decreased compliance, decreased gas exchange, hypoxemia DIC (Disseminated Intravascular Coagulation) Causation Factor Any causes of disequilibria in the balance of clotting versus lysis History: Recent Pregnancy Multi-System Trauma Cancer Infection Signs & Symptoms: Bleeding from odd sites: o Gums, Nail Beds, Eyes, IV Puncture Sites Thrombocytopenia Decrease of clotting factors Acute Renal Failure Acute Hepatic Failure Management: Treat underlying cause Treat loss of blood & constituents Heparin Therapy as required

Shock
Definition: Cells become hypoxic because of inadequate perfusion of the tissues. 4 Categories of shock: 1. Hypovolemic (Loss of volume) Burns, Hemorrhage, Gastroenteritis, Spleen Rupture 2. Cardiogenic (Loss of pump) Acute/ Chronic Cardiac Patients, TB Patients, Trauma Patients 3. Distributive (Loss of competency of vasculature) Septic, Neurogenic, Anaphylactic 4. Obstructive (Loss of pathway) Airway Obstruction, Cardiac Tamponade, Tension Pneumothorax

Stages of shock: 1. Compensatory 2. Progressive 3. Irreversible Cellular Effects of Shock: o Decreased ATP production o Excess Lactic Acid Production o Mitochondrial Death o Cellular Edema o Deterioration of the sodium-potassium pump Crystalloids are administered @ a 3:1 ratio Blood products are administered @ a 1:1 ratio

CCEMT-P Notes Day #3


Blood Administration
Hematocrit The percentage, by volume, of RBCs in a whole blood sample. Symptoms of Anemia: o Pallor, weakness, vertigo, dizziness

Whole Blood o Complete blood, unadulterated except for anticoagulants. o Cross-Match Necessary o Indications: Hypovolemic shock Acute hemorrhage Exchange transfusion Surgery Obstetrics Packed Red Blood Cells (PRBCs) o Contains all characteristics of Whole Blood, minus plasma. o Indications: Anemia CHF Surgery Fresh Frozen Plasma (FFP) o Contains clotting factors o For low PT/ PTT o Must be infused within 24 hours of being thawed o Indications: Active bleeding Hemophilia Thrombocytopenia Type & Screen o Indications: Blood Loss Anemia Surgical Work-Up o Procedure: Phlebotomy Spin & Separate Test for antibodies

Cross Matching o Indications: Specific blood for specific patient (O) Universal donor (AB) Universal Recipient

Both

RH Factor o Rh Positive Possess D Antigen o Rh Negative Possess no D antigen Rh Negative patients may develop D Antigen Blood Administration o Equipment needed: Physicians order Blood Type & Matched Large Bore Venous Access Filtered Administration Set Isotonic NS Thermometer o Transfusion Procedure: 1. Flush tubing with NS 2. Inspect Blood 3. Cover administration with blood 4. Connect Blood Tubing 5. Piggyback IV line of NS 6. Slowly start transfusion 7. Monitor for adverse reactions 8. Have at least two IV Sites o Transfusion Rate Procedure: Initial Rate of 1 ml/min Evaluate for hemolytic reaction Monitor vitals every 15 minutes

After 30 minutes adjust flow rate Evaluate for hemolytic reaction Monitor vitals every 30 minutes Transfusion Reaction: Fever Hives, Itching or skin symptoms Swelling or soreness @ IV site Tachycardia Respiratory Distress Hypotension Anaphylaxis Nausea/ Vomiting Blood in Urine Treatment of Transfusion Reaction: 1. STOP the Transfusion! 2. Maintain IV access with Isotonic NS 3. Save the remaining blood product 4. Administer Oxygen PRN Treatments continued: o Medications: Benadryl Epinephrine Tylenol Lasix

Pediatrics
General Pediatric Assessment: o Identify baseline findings o Systems Assessment o Vital Signs o Toe to Head Assessment Pediatric History: o Activity Level o Feeding/ Fluid Pattern o Perinatal history if under 1 year old Transport Considerations: o Double check fluid rates and medications o Secure Lines & Tubes SBP is = (90) + (2X Age in years) Rewarm Children @ no more than 1 Degree Celsius/ Hour

Dialysis

Function of the Kidneys: o Control bodys Water Balance o Regulation of Blood Pressure (Renin-angiotensin) o Electrolyte Balance (Na+, Ca2+, K+, etc) o Excretion of Metabolic Wastes (Urea, creatinine) o Acid/ Base Balance o Regulation of Red Blood Cell Production (erythropoietin) o Production of Vitamin D

Indications for Dialysis: Traumatic renal Insufficiency, End-Stage Renal Disease Dialysis Transport Complications: o Bleeding o Infection o Infiltration o Abdominal Pain o Signs of electrolyte & chemical Imbalances Hyper/ Hypoglycemia Sodium/ Potassium imbalances Hemodialysis: Vascular Access through either a fistula or arteriovenous shunt Peritoneal Dialysis: Introduction of Dialysate solution into the abdominal cavity with a catheter Accessing an Arteriovenous shunt: Need to know these steps! 1. 2. 3. 4. 5. 6.

CCEMT-P Notes Day #4


Neurological Assessment
Cranial Nerve I & II are the only nerves that do not cross Ipsilateral Same side affected Ansicoria Unequal Pupils Nystagmus Shaky eye movement Major Components of Neurological Exam: o External Assessment o Level of Consciousness o Eyes, Pupil Size/ Reaction o Motor Response o Vital Sign Changes Localization of Pain: Patient crosses the midline to localize centralized pain (+) Babinski Reflex Cerebellar Reflex Cranial Nerves: o I Olfactory: Smell o II Optic: Vision o III Oculomotor: Ocular movement, Pupil Reaction o IV Trochlear: Ocular Movement, Pupil Contraction o V Trigeminal: Chewing o VI Abducens: Ocular movement o VII Facial: Cheek & Jaw (expressions) o VIII Acoustic: (Auditory): Hearing & Balance o IX Glossopharyngeal: Taste, Visceral Sensation, Gland Secretions o X Vagal: Speech, Swallowing, Uvula movement o XI Accessory: Speech, Swallowing, Movements of Head & Shoulders o XII Hypoglossal: Swallowing, Tongue Movements 3 4 6 make your eyes do tricks! o CN III Me o CN IV Floor o CN VI Sticks (lateral) Neurogenic Shock Vital Signs: o Bradycardia o Hypertension o Hyperventilation Transport Considerations? o Maintain Airway o Proper Positioning of ET Tube o Hemodynamic Stability o Physicians Orders o Equipment Requirements Spinal Injured Patient: Key: Green Cervical Blue Thoracic Purple Lumbar Orange Sacral

Proprioception: The ability to discern where you are in space. (Spinal cord patients lose that ability) Poikilothermia: Loss of thermal regulation, patient will assume ambient temperature Spinal Shock: Profound disruption of the spinal cord o Bradycardia o Hypotension o Flaccid paralysis o Sensory loss below the level of injury o Loss of bowel & bladder function o Loss of temperature control o Priapism Orthostatic Hypotension: Result in a loss of peripheral resistance Autonomic Dysreflexia: An exaggerated sympathetic response which results in uncontrolled hypertension o Serious Hypertensive Emergency o Patients with injury @ T-6 and above

Intracranial Pressure & ICP Monitoring


Intracranial Pressure: Pressure exerted by brain tissue, blood and CSF in a closed cavity (Monroe-Kellie) o 80% - Brain Mass o 10% - Blood Volume o 10% - CSF (Cerebral Spinal Fluid) Reasons for increased ICP: o Cerebral Edema, Hydrocephalus, Trauma, Tumor, Abscesses, Stroke, Bleeding/ Clots/ Bruises Cerebral edema develops and peaks in 3 5 days Autoregulation: o Metabolic Autoregulation buildup of metabolic byproducts (CO2), Triggers Vasodilation o Decompensation: The point when Autoregulation has failed Cushings Response: Compensatory Ischemic Response o Cushings Triad: Bradycardia (Compression on Brain Stem) Hypertension (Rise in systemic Blood Pressure) Widening Pulse Pressure (Drop in diastolic BP, Rise in systolic BP) MAP = [(2 X Diastolic + Systolic) / 3] Cerebral Perfusion Pressure (CPP): Constant pressure assuring blood flow (02 & glucose) to brain o MAP ICP = CPP o Goal: CPP > 60 < 50 Mild Cerebral Ischemia < 40 Cerebral blood flow down 25% < 30 Irreversible Cerebral Ischemia If MAP = ICP (BRAIN DEATH) Herniation: Displacement of the brain from one compartment to another

o a) b) c) d) e)

Places Herniation Occur: Cingulate Uncal Central (Transtentorial) External Tonsillar (Cerebellar)

Factors that will Increase ICP: o Positional Changes o Coughing (Valsalva Maneuvers) o Body Temperature o Drainage of Interventricular Cannula o Medications o Environmental Considerations Strategies for Decreasing ICP: o Fentanyl, Morphine (Analgesia) o Versed, Ativan (Benzodiazepine Sedation) o Propofol (Sedation) o Ventilation (Hyperventilation when herniated) o Diuretics (Draw off excess fluid [Osmotic or Loop]) o Paralytics (Eliminate Pain Response) o Fluids 3% NaCl (Pull off fluid excess) o Vasopressors (Maintain MAP) o Potassium ([Hypokalemic] Because of Loop Diuretics) o Insulin (Combat release of cortisol) o Methylprednisolone (Spinal Cord Injuries) Compliance Change in volume divided by the change in pressure CSF Drainage: o If IVC (Interventricular Cannula) in place, open & close Over-drainage = herniation Under-drainage = hydrocephalus o Level IVC @ the ear Intracranial Pressure Waveforms: o Normal ICP between 0 -15 mmHg o Severe rise in ICP caused by a small increase in volume, looks like: A Vertical inflection Point

Aeromedical Physiology
Boyles Law o At a constant temperature, the volume of gas varies inversely with the pressure o As you go up, air will expand o *** More than 15% Pneumothorax Put in a chest tube o Fill ETT with fluid Daltons Law o In a mixture of gases, the total pressure is equal to the sum of the partial pressures of each gas o O2 Availability decreases with altitude o Altitude increase, decreases barometric pressure o *** Patient will require increased oxygen delivery at higher altitudes

Place patient in LLR Trendelenburg (Durants Position) if suspected Air Embolus/ Bends Eight Stressors of Flight: 1. Hypoxia 2. Barometric Pressure 3. Temperature Changes 4. Decreased Humidity 5. Noise 6. Vibration 7. Fatigue 8. G-Forces Hypoxia: o Hypoxic Hypoxia Deficiency in alveolar O2 exchange o Hypemic Hypoxia Deficiency in the O2 carrying capability of blood Signs & Symptoms: Objective: o Dyspnea, Tachypnea o Tachycardia, Bradycardia, Arrhythmias o Hypertension, Hypotension o Slouching, Euphoria, Belligerence o Confusion, Restlessness, Unconsciousness Subjective: o Personality & Judgment Changes o Hot & Cold Flashes o Head Ache, Blurred Vision, Dizziness, Tunnel Vision o Nausea o Confusion, Stupor, Insomnia, Anger, Euphoria o Numbness o Inability to rationalize sight, taste, sound or pain Time of Useful Consciousness: o Below 18,000 ft. (30 minutes) o 25,000 ft. (3 5 minutes) o 30,000 ft. (90 seconds) o Greater than 40,000 ft. (< 15 seconds) Contributing Factors to Crew-Member Fatigue: o Drugs o Exhaustion o Alcohol o Tobacco o Hypoglycemia

CCEMT-P Notes Day #5


Hemodynamics
Preload Ventricular filling during diastole Afterload Resistance against which the heart contracts o Determines the amount of volume the heart can pump Contractility Cardiac performance independent of preload or afterload o Factors that decrease contractility: Anoxia, Acidosis Medications (Beta Blockers, etc.) CHF, MI Vagal Maneuvers o Factors that increase contractility: Sympathetic Nerve Impulses Natural Catecholamines Positive Chronotropes Ejection Fraction Percent of blood the ventricle actually pumps out o Normal EF is 55% 75% Mean Arterial Pressure Average of Blood Pressure o 2 X Diastolic + Systolic / 3 = MAP Cardiac Output Amount of blood flow in LPM o (CO) = HR X SV / 1000 o Decrease in CO: Decreased preload, diuresis, arrhythmias, MI, increased afterload, SVR o Increase in CO: Fever, Pain, Inotropic Pharmacology Stroke Volume Amount of blood that is ejected in one contraction o SV = (CO) /(HR) X 1000 o Normal SV is 60 100 ml Systemic Vascular Resistance (SVR) Resistance to the Left Ventricle created by arterial contraction/ dilation o SVR = 80 X (MAP RAP) / CO o Normal SVR is 800 1200 dynes/sec/cm squared o Increase in SVR in due to vasoconstriction o Decrease in SVR due to vasodilation Pulmonary Vascular Resistance (PVR) - Resistance to the Right Ventricle created by pulmonary artery contraction/ dilation o Normal PVR is 40 100 dynes/sec/cm squared

Hemodynamic Monitoring
Types: o Arterial MAP (Mean Arterial Pressure) o Venous CVP (Central Venous Pressure) o Pulmonary PAP, PCWP (Pulmonary Artery Pressure, Pulmonary-Capillary Wedge Pressure) th Phlebostatic Axis 4 Intercostal Mid-Axillary To zero a hemodynamic monitor, open it to air

Waveforms Types: o o o o Atrial Waveforms Ventricular Waveforms Pulmonary Artery Waveforms Arterial Waveforms

Dicrotic Notch An increase in Aortic Pressure that signals the start of diastole Central Venous Monitoring Evaluates net volume and Right Atrial Pressure (RAP) o Normal CVP or RAP is 2 -6 cm H2O o Increased CVP = Hypervolemia o Decreased CVP = Hypovolemia Pulmonary Artery Catheter (Swan-Ganz Catheter) Measures: o Right Atrial Pressure (RAP) o Pulmonary Artery Pressure (PA) o Pulmonary Artery Capillary Wedge Pressure (PCWP)

Complications: o No waveform: Transducer is not open to the catheter o Dampened Waveform: Improper monitor calibration Clot or air bubble in catheter Aspirate, NEVER irrigate first Blood in the transducer o Continuous PCWP Wedge Waveform: /.Catheter Migration Have the patient cough o No PCWP Wedge Waveform: Incorrect position of the catheter Insufficient air in the balloon Balloon Rupture Swan-Ganz Catheter Diagram:

Laboratory Data Interpretation


Sensitivity Test will be positive in the presence of disease Specificity Test will be negative in the absence of disease K+ will read high in hemolyzed blood drawn Complete Blood Count (CBC) o Hematocrit (HCT) 45 Volume of blood occupied by erythrocytes Normal HCT is 40% -50% (male), and 35% - 45% (female) Decreased HCT: Anemia, Hemodilution Increased HCT: Polycythemia, Hemoconcentration o Hemoglobin (HGB) 15 Oxygen Carrying Protein Normal HGB is 14 -18g/dl (male), and 12 -16g/dl (female) Increase in HGB: Polycythemia, COPD, CHF, Altitude sickness Decrease in HGB: Anemia, Hyperthyroidism, Live Cirrhosis, Hemorrhage o Red Blood Cells (RBC) 5 Diagnose Anemia & Indication of good Hydration Normal RBC is 4.5 6.0 Increase RBC: Similar for HCT, HGB Decrease RBC: Similar for HCT, HBG Differential Blood Count (DBC) o White Blood Cells (WBC) White corpuscles in blood (host defenses) Normal WBC is 5,000 10,000 cells/mcl Infant white counts are higher Decreased WBC: Influenza, Measles, Rubella, Hepatitis, AIDS, Rubella, Typhoid Increased WBC: Infection, Leukemia, Trauma, MI o Measures the percentage of different types of WBCs: Neutrophils: 2500 8000/mm cubed Basophils: 25 100/ mm cubed Eosinophils: 50 55--/mm cubed Lymphocytes: 1000 4000/ mm cubed Monocytes: 100 700/mm cubed o LEFT SHIFT Early type of active bacterial infection

Platelet Count (Thrombocytes) o Cell important for coagulation and hemostasis o Normal Platelet Count is 150,000 400,000 mcl o Decreased Platelets: Leukemia, Splenic Injury, Bone Marrow Disease o Increased Platelets: Hemorrhage, Anemia (Iron Deficiency), Surgery, Splenectomy, Trauma Blood Chemistry o Looks for Electrolyte & Metabolic Balances/ Abnormalities o Basic Metabolic Panel (BMP) Glucose Chief source of energy in the blood Normal Glucose Value is 70 -110mg/dl Increase Glucose: DM, Cushings, Pancreatitis, Hyperthyroidism Decrease Glucose: Addisons, Hypothyroidism, Bacterial Sepsis

Blood Urea Nitrogen (BUN) Metabolic byproduct from the breakdown of blood, muscle and protein Normal BUN is 8 20 mg/dl Increase in BUN (Azotemia): Kidney Disease, CHF, Gastrointestinal Hemorrhage Decrease in BUN: Excessive Hydration/ Fluids, Pregnancy

Creatinine Waste product of protein metabolism found in urine Normal Creatinine is 0.5 1.2 mg/dl BUN/ Creatinine Ratio is normally 10:1 or less. Greater than 10:1 is an indicator of renal failure Sodium Electrolyte: Alkali Metal Normal Sodium is 135 145 mEq/l Decreased Sodium: Diarrhea, Vomiting, Diabetic Acidosis Increased Sodium: Cushings, Diabetes Insipidus Potassium Electrolyte: Alkali Element Normal Potassium is 3.5 5 mEq/l Decrease in Potassium (Hypokalemic): V-Fib Increase in Potassium (Hyperkalemic): Asystole Sine Wave --------------------------------------------------------Creatine Phosphokinase (CPK) Enzyme broken down in muscles Increased CPK: Rabdomyolysis, Hypokalemia, Hypothyroidism, Trauma, Damaged Cardiac Muscle, Cerebrovascular Disease, Electrical Burns Troponin I & T Requires myocardial necrosis for release Early Rise 4 12 hours Peak in 12 -24 hours B-Type Natriuretic Peptide (BNP) Release from the ventricles in response to stretch from extra volume Normal BNP is <100 100 -400: COPD, CHF, Renal Failure 400+ Renal Failure or CHF ***Test will not work if patient on dialysis Bilirubin Pigment produced as the liver processes waste products Cholesterol Normal cholesterol is 140 220 mg/dl Amylase Normal Amylase is 50 -190 u/L Decreased Amylase: Pancreatitis Increased Amylase: Pancreatitis, Alcohol Poisoning Lipase Normal Lipase is 4 -24 u/dl Increased Lipase: Pancreatitis, Cirrhosis, Renal Disease Magnesium Normal Magnesium is 1.3 2.11 mEq/L

Lactate Used to find lactic acidosis Normal is 0.93 -1.65 mmol/L

Urinalysis

Normal Urine Output 30+ccs/hour PT Checks for Coumadin Level PTT Checks for Heparin D-Dimer Diagnose: Abruptio Placenta, DIC, DVT, PE

CCEMT-P Notes Day #6


Transport Start to Finish
The Big Four (Positive interaction for a Critical Care Transport) o Contact with referring staff o Contact with the patient o Touch, procedures and equipment o Contact with receiving staff Prospective Protocols o General Protocols o Case Specific Contingency Orders Critical Decision Points in a Transport: o Should we take the call? o Additional help or equipment? o Appropriate Destination? o Medical Support? o Call for intercept? o Divert to another facility? o When is the call over? Event Flow Sheet: 1. Before the Call Promote the Service 2. Request Caller, Facility, Location 3. Activation Resources, Priorities 4. Response Check equipment, communications, vehicle 5. Arrival Mentally prepare for patient, family & staff contact 6. Receive Turnover Report Receive Report from Direct Caregiver 7. Assessment Expect the unexpected! 8. Transition for Transport Do not leave patient unmonitored 9. Transport Vitals q 15 minutes 10. Transition for Arrival Direct Communication with receiving caregiver 11. Arrival Ensure facility has appropriate staffing and equipment 12. Provide Turnover Report Introduce patient by name, not diagnosis 13. After the Call Debrief Issues arising en route

Cardiac Pacemakers & Implantable Cardioverter Defibrillators


Cardiac Pacemakers o o Capture Pacemaker induced depolarization Components: Power Source: Battery Unit called a pulse generator Conducting Wire: Electrode that provides stimulus Returning Wire: Wire that returns to battery (completes circuit) A V Synchronous Stimulates both the Atria & Ventricles in sequence (Restores Atrial kick) Single Chamber stimulate either the Atria or Ventricles, but not both Dual Chamber Stimulate both Atrial & Ventricular chambers

o o o

o o

Pacing Response Triggered: Fixed Rate, Predetermined Rate, Does not regard underlying activity Inhibited: fire only when needed, Demand Pacemaker, Inhibit stimulus when they sense a patients complex Ventricular Pacemakers Stimulate only the ventricles Most all pacemakers have this function Atrial Pacemakers Depolarize the Atria & the hearts own conduction system is relied upon to depolarize the ventricles Common Types of Pacemakers: Single-Chamber Pacemakers Ventricular Demand Pacemaker (VVI) o Most common o Paces only when needed Atrial Demand Pacemaker (AAI) o Maintains the sequence of Atrial & Ventricular Contraction Dual-Chamber Pacemakers: A V Synchronous Pacemaker (VDD) o Senses Atrial & Ventricular Activity, but only paces the Ventricles A V Sequential Pacemaker (DVI) o Senses only Ventricular Activity, but paces chambers sequentially Optimal Pacemaker (DDD) o Fully automatic o Senses Atrial & Ventricular Activity o Paces either Atria, Ventricles or both Electrical Impulse Sharp, superimposed spike on the patients rhythm Troubleshooting problems should always start with the patient!

Implanted Cardioverter Pacemakers o o o Stay away from an MRI! First Human Implant of an ICD (1980 @ John Hopkins University Hospital) ICD Weight 97 -116 Grams

o o o o o

1985: FDA Approved First Generation ICD Devices Pectoral region - accounts for 98% of ICD placements Amiodarone results in increased defibrillation threshold 6 8 weeks after introduced Place AICD leads as far away as possible from pacing electrodes Magnets will either turn off or suspend therapy from the ICD

CCEMT-P Notes Day #7


*www.NCBurndisaster.org*

Burns
Skin & its Effects on Burns: o Epidermis Sheading Skin o Skin: Largest Organ on body o Hydrostatic Pressure: Due to Water volume in body o Oncotic Pressure: Exerted by plasma proteins First Degree Burn: o Sunburn, Heat, Hot Liquids Second Degree Burn (Partial Thickness): o Chemicals, Flash Burns, Hot Liquids, Deep Sunburn o Extremely Painful, Red, Blistered, Painful Third Degree Burn (Full Thickness): o Fire, Deep Scald, Electricity, Chemicals o Pale White, Charred, Leathery, Painless

Burn Management: 1. All patients need 100% O2 Therapy & SaO2 Monitoring 2. Early intubation in these patients: Obtunded/ Confined Space Tachypnea, Stridor, Labored Breathing Inhalation Injury Largest ETT Possible 3. Tetanus Status? 4. Fluid resuscitation for all burns > 20% BSA 2 Large Bore IVs st Lactated Ringers for 1 24 hours st Fluid Resuscitation for 1 24 hours Do Not delay transport to gain IV access 5. Foley Catheter to monitor hourly I/O 6. NG/OG tube 7. Prevent Hypothermia

Rapid Sequence Induction & Difficult Airways


Indication questions for RSI: o Can the patient maintain their airway? o Can the patient protect this airway? o Is the patient appropriately ventilated? o Is the patient appropriately oxygenating? o Is the patients condition likely to deteriorate? o Is the scene appropriate? (Safety, moving the patient while apneic) Indication: Where respiratory arrest is imminent Trixmus A clenched jaw Glottic Opening in Child: o Level of C-3/ C-4 (Age 7) o Level of C-1 (Infant) RSI Contraindications: o Burns or Crush Injuries over 5 days old o Hyperkalemia o Malignant Hyperthermia Rare - 1:15,000 patients o Neuromuscular Disorders The 7 Ps: 1. Preparation Assess the Risk Difficult to: BVM, Laryngoscopy, Intubate, Cricothyrotomy Prepare the equipment Monitor the Patient 2. Pre-Oxygenation For At Least 2 Minutes @ 100% 3. Premedication Lidocaine for Increased ICP (1.5 mg/kg) Atropine to prevent Bradycardia (0.5 mg) Correct Hypoxia First! Fentanyl as an Analgesic (3 Mcg/Kg) 100X more powerful than MS May cause chest wall rigidity Sedatives [Benzodiazepine] Midazolam for sedation (0.1 mg/kg) o Causes Hypotension & Bradycardia [Barbiturate] Thiopental for Head Injury Sedation (3-4 mg/kg) o NO Asthmatics! [Nonbarbiturate-analgesic-hypnotic] Etomidate for sedation (0.3 mg/kg) o Little to no side effects [Dissociative-anesthetic-analgesic] Ketamine for sedation (1-2 mg/kg) o PCP derivative [Sedative-Hypnotic] Propofol for sedation or anesthesia o Initiate @ (5 Mcg/kg/min) o Increase @ (5 10 Mcg/kg/min) o Titrate every 5 10 minutes o Max dose @ (50 Mcg/kg/min) 4. Paralyze [Depolarizing Nerve Agent] Succinylcholine for Paralysis (1 1.5 mg/kg)

5. 6.

7.

Order of Paralysis: 1. Eyes, face, Neck 2. Extremities 3. Abdomen 4. Intercostals, Glottis 5. Diaphragm Pass the Tube Proof of Placement Objective Visualization Spo2 CO2 Detector Subjective Negative Epigastric Sounds Mist in the tube Positive Lung Sounds Equal Chest Rises & Fall Post Intubation Care [Non-Depolarizing Agent] Vecuronium (Norcuron) for paralysis (0.1 mg/kg) Duration of 20 30 minutes [Non-Depolarizing Agent] Rocuronium (Zemuron) for paralysis (1 mg/kg) Duration of 20 75 minutes

CCEMT-P Notes Day #8


Capnography
Indications Monitoring: Hypoventilation, Apnea, CO2 Waveform & Parameters of Mechanical Ventilation Cardiac Resuscitation Survivors: > 10 ETCO2 Level Normal PaCO2 = 3545 mmHg Normal ETCO2 = 3043 mmHg V/Q Mismatch Ventilation/Perfusion Mismatch Gradient between 2-5 mmHg between PaCO2 and ETCO2 Increase indicates mismatch Dead Space Air Bronchial Tree Peak Expiration (Beginning of Inspiration) - Alveolar Gas Exchange Quantitative ETCO2: Actual numeric value Qualitative ETCO2: CO2 Detectors

A Baseline B Expiratory upstroke C Expiratory Plateau-----------------------------D Inspiration Begins

Rebreathing Rise in ETCO2 Baseline (COPDers)-----------

Muscle Relaxants Curare Cleft------------------------------

Bronchospasm Shark Fin------------------------------------------------------------------

Arterial Blood Gases (ABGs) & Acid/ Base Balance


Drawn from an Artery Radial, Brachial, Femoral, etc Diagnoses pH - [H+] PaCO2/ CO2 - Partial Pressure of Arterial CO2 PaO2 - Partial Pressure of 02 HCO3 Bicarbonate BE - Base Excess SaO2 Arterial Oxygen Saturation pH is a measurement of the acidity or alkalinity of the blood Normal Ranges:-------------------------------------------------------------ACIDIC STATE Decreases: Force of Cardiac Contractions Vascular Response to Catecholamines The Effects & Actions of certain medications ALKALOTIC STATE Interferes with: Tissue Oxygenation Neurological & Muscular Function pH above 7.8 or below 6.8 will cause death Bicarbonate Buffer System Respiratory Buffer System Renal Response System R.O.M.E. Pneumonic: ------------------------------------------------------- Acidity/ Alkalinity is measured using pH

Modified Allens Test

Performing an ABG Procedure: o Perform Modified Allens Test o Cleanse the Area o Hyper-Extend the wrist o Palpate the Arterial Pulse o Line the needle up to 45 Degrees and puncture (Bevel Up) o Withdraw the needle, Hold pressure o Invert syringe several times

12-Lead Electrocardiogram -Lead Placement & AcquisitionIf you have a pulse and a problem You should be doing a 12-Lead. -Bob Pageo Limb Leads (Bipolar): Positive looks towards negative Einthovens Triangle--------------------------------------------------Precordial Leads (Unipolar): V1-V6 Placement based on Anatomical landmark Placement------------------

-12-Lead Analysis-

o o o

Q/T Interval should be 1/3 the R/R Interval R Wave Progression-----------------------------------------------Axis Deviation:

-Determining Axis & Hemiblockso Normal Axis - downward & to the left

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Ventricles out of sync: RSR Prime-------------------------------------------------------------Incomplete BBB: QRS Duration between 110-119 ms

LBBB Negative deflection in V1---------------------------------------

RBBB Positive deflection in V1----------------

-The 15-Lead ECGo o o o o 12-Lead Misses 50% of AMIs 23 out of 100 MIs could be missed for not doing this 15-Lead ECG increases sensitivity by 23% V4R-----------------------------------------------------------------------Up to 50% of Inferior MIs have Right Ventricular Involvement

Posterior (V8 & V9)-------------------------------------------------

CCEMT-P Notes Day #9


Fetal Heart Monitoring & Obstetrics
o Physical Assessment: Confirm PMI (Point of maximum Impulse)

Leopolds Maneuver-------

o o

Clonus Test Shaking Foot Post Pedal Flexion o No Response - 0 o Less than normal - 1+ o Normal - 2+ o More than normal - 3+ o Brisk - 4+ o Sustained (Seizure) - 5+ Station--------------------------------------------------------------------------Effacement:

o o o o o o

Gravita Term babies Premies Abortions Live Births Multiple Births

-Emergencieso Emergency Childbirth: Rarely Needed in the field Support Perineum Keep baby lower than perineum

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Clamp, cut & tie cord Warm baby & APGAR Baby to Moms chest Record time & place Start Pitocin @ 250 ml/hr (40 Units/1000 ml NaCl)

Types of Breech Presentation:----------------------------------------Post-Partum Hemorrhage: 4 Ts: Tone 70% Inability to contract Uterus Leads in increased bleeding Trauma 20% Tearing away of placenta Ruptured Placenta Tissue 10% Expelled fetal product Can cause increased bleeding Thrombin 10% Bleeding disorder of Mom 3 Trimester Bleeding Irregular, No contractions Heavy Bleeding Prolapsed Cord Ruptured Membrane Presenting part occluding cord (Babies blood flow) PROM (Premature Rupture off Membranes) Rupture prior to 37 weeks gestation Pre Eclampsia Hypertension >140/90 Proteinuria 1+ or >300 mg/24 hours Generalized Edema Must have ALL 3 to have Pre Eclampsia Foley to measure I&O Eclampsia Seizures
rd

-Fetal Monitoring Rhythmso Deceleration: Early deceleration is GOOD! Late deceleration is BAD! Variability: V-Fib is good!

CCEMT-P Notes Day #10


Ventilators
o Types of Ventilation: Pressure Cycled Ventilation: Inspiration ends at a preset airway pressure VT is variable Patient is unconscious or sedated Volume/ Time Cycled Ventilation: Most popular and easily applied Essential parameter to control is volume delivery Tidal Volume (VT) & Minute Volume (VE) are predictable Modes of Ventilation: Control Machine is fully responsible for patients respiratory drive Assist/ Control Machine will breathe when patient wants to take a breath Synchronized Intermittent Mandatory Ventilation (SIMV) Patient cannot take machine breath, but can still spontaneously breathe Continuous Positive Airway Pressure (CPAP) VT & flow rate are completely patient controlled Pressure Control No minute volume guaranteed Pressure Support IPAP, BIPAP Terminology: (FiO2) Fraction of Inspired Air (VT) Tidal Volume Amount of gas moved in one normal breath About 500 ml or 10-15 ml/Kg (VD) Dead space Remaining gas in upper airways that does not participate in alveolar gas exchange (f) Frequency Breaths per Minute (VE) Minute Ventilation (VT) X (f) Flow Rate Inspiratory Time I time (LPM) X Flow Rate = (VT) I:E Ratio Normally 1:2 Airway Pressure Actual (PAW) o Real time airway pressure Mean (MAP) o Average of one completed ventilatory cycle Peak

Highest pressure of one completed ventilatory cycle

Compliance Resistance of the lungs to a positive pressure breath o Increased Compliance Lungs are more receptive to a ventilator o Decreased Compliance (Positive End Expiratory Pressure) PEEP Positive pressure allows alveoli to stay open Clinical Guidelines: (VT) 10-15 ml/kg (f) 10-20 breaths per minute FiO2 ABG (PO2) or SpO2 Flow Rate 30-60 lpm (I:E ratio) PIP <40 lpm (VE) ABG(PCO2/ PH) ETCO2 Sigh 1.5-2 times VT Sensitivity -2 cm (adjust as tolerated) High Pressure Limit 10-15 cm above PIP Low Pressure Limit 10-15 cm below PIP

CCEMT-P Notes Day #11


Pharmacology
o Critical Care Environment Hows it different? What to expect?? What could be on the test? Haloperidol o Post-Synaptic Dopamine Antagonist Romazicon o Benzodiazepine Antagonist Propofol Succinylcholine Crystalloids/ Colloids o Colloids have larger molecule & typically stay intravascular, where Crystalloids move interstitial Integrilin Calcium Channel Blockers (Diltiazem) Lidocaine Pharmacology Pharmacodynamics Pharmacokinetics Agonist: Turn on Antagonist: Turn off Half-Life: Time it takes half of drug to be eliminated Bioavailability: How soon will a medication take to be available in the body Chronotropic: Time (Rate) Inotropic: Force (Pressure) Beta 1 Heart Beta 2 Lungs (Cerebellum) Beta 3 Adipose Tissue Alpha 1 Skin & GI Alpha 2 Alpha 1s checkmate

o o o o o o o o o o o o o o

CCEMT-P Notes Day #12


Intra-Aortic Balloon Pumps (IABP)
www.Datascope.com

Balloon pump: o Inflates at the beginning of diastole (Perfuses Coronary Workload) o Shuts before systole (Decreases Workload) o Normal balloon inflation is 30cc (Helium) o Can monitor SVR o Can draw blood Counter-pulsation: o Increases oxygen supply & Decreases oxygen demand Trigger: o Onset of new cardiac cycle Timing: o Start & End of Balloon inflation/deflation Augmentation: o Amount of benefit from IABP o Systolic is increased o Diastolic is decreased Frequency: o How often balloon inflates: I.e.: (1:1), (1:2), (1:3) (1:3) Commonly used to wean patient off IABP Indications: o CHF o Left Ventricular Failure o Cardiac Surgery o Weaning off bypass machine o Unstable Angina Contraindications: o Aortic dissection or regurgitation Things to remember: o Constantly monitor pedal pulses o Constantly monitor left radial pulse Balloon could be too high o Blood in the tubing: Balloon has ruptured o Machine failure: Inflate and deflate Half of balloons volume Balloon pumps are mechanical Nitroprusside

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