Contexto de sostenibilidad
CONTENIDOS BÁSICOS GENERALES
STEMI
Note:
• On-Scene (early) initiation of aeromedical transport (by EMT) and activation of appropriate PCI team (by ED Physician) will ensure meeting the AHA recommended, 90 minute first contact to balloon time.
• Appropriate PCI facility depends on many factors: location of call, patient preference and condition of patient. PCI times will be monitored and locations adjusted as needed.
• Early 12-Lead acquisition prior to treatment is essential to identifying STEMI
Priorities Assessment Findings
Chief Complaint Heavy, vague, squeezing, pressure like, dull or achy, discomfort or pain OPQRST Identify location and radiation, onset, duration progression and severity, presence of intermittent or fluctuating symptoms, factors that provoke (exertion) or palliate (rest) the pain.
Associated Symptoms/
Pertinent Negatives
Radiation, dyspnya, nausea/vomiting. Pain that is aggravated by breathing and coughing (pleuritic). Cough and fever/chills.
SAMPLE History of coronary artery disease or risk factors for it. Use of cardiac medications, including aspirin.
Initial Exam Check ABCs and correct any immediate life threatening problems.
Detailed Focused Exam Vital Signs: BP, HR, RR, Temp, SpO2
General Appearance: Anxious?
Skin: Cool, pale diaphoretic?
Neck: JVD?
Chest: Laboring to breathe?
Lungs: Wheezes, rales, rhonchi? Decreased breath sounds?
Heart: Rate, regularity?
Legs: Pedal Edema?
Neuro: ALOC?
Data SpO2, 12-Lead ECG, Blood Sugar if Diabetic, EtCO2 if ALOC
Goals of Therapy Reduce chest pain; reduce risk of lethal arrhythmias; early identification of myocardial infarction, and early identification of PCI therapy candidates.
Monitoring Cardiac monitoring, SpO2 and serial 12-Leads
EMERGENCY MEDICAL RESPONDER
• Assist ambulance crew as needed, O2 applied and vitals taken prior to 12-Lead identifying STEMI
EMT
• Pull out and utilize “STEMI Envelope” to ensure steps are followed and continuity of care
• Call FFL (800-344-1000) for aeromedical intercept to closest hospital helipad, use the word
“STEMI” and give gender, age and cath lab destination. If unsure at this time, use Janesville, it can be changed later. FFL will notify designated pickup hospital of status
• Ensure ALS has been dispatched to scene, then continue with Chest Pain Guidelines
• Transmit to “MERCYWALWORTH” for Medical Director (ED Physician) to activate cath lab o Print copy to place in envelope
o If going to NIMC (closer) transmit to “CENTEGRANIMC”
• Determine cath lab choice with patient (provide education on the importance of time and choices).
Relay the patient’s request and discuss with the Mercy Walworth ED physician. Confirm FFL or ALS transport
INTERMEDIATE
Contact Medical Control for the following:
• Confirm STEMI, ensure aeromedical transport was called to closest hospital helipad and call Mercy Walworth ED. Early activation of reperfusion strategy is critical. Inform ED physician of patient’s choice of cath lab. If helicopter not flying, see footnote [1]
PARAMEDIC
• 12-Lead EKG shows an acute STEMI, confirm, follow Chest Pain Protocol, transport to appropriate facility [1]. Continue with SL nitro or 1” paste as BP allows even when pain free If bypassing closest ED direct to cath lab:
• Highly recommend transport with two personnel in back of ambulance
• Metoprolol (Lopressor) 5mg IV (x3 every 5 minutes) or until contraindicated [2]
• Heparin Sulfate 5000units IV bolus unless contraindicated [3]
• If right side involvement, acquire modified 12-Lead with V4R, mark as such [4]
• Call in report and complete checklist [5]
FOOTNOTES:
[1] For good weather, proceed directly to closest hospital helipad. If helicopter is not seen or has not landed, proceed inside to ED. For bad weather (helicopters not flying) after discussing with Mercy Walworth ED Physician, proceed to closest PCI capable facility, or patient’s choice of PCI facility, educate appropriately, time is of the essence:
• Mercy Hospital Janesville proceed direct to ED (608) 756-6611
• Prohealth Care Waukesha proceed direct to ED (262) 928-2000
• St. Luke’s Medical Center, unload at direct admit [cath lab RN report, (414) 649-6589, unstable enroute, proceed to ED to unload, (414) 649-6989 for report]
• Northern Illinois Medical Center proceed direct to ED (815) 385-9080
• Wheaton Fransiscan (All Saints/St Marys) [2] Contraindications for Metoprolol (Lopressor)
• SBP < 90 mmHg
• HR < 60
• Acute Asthma/COPD/CHF
• 2nd or 3rd degree heart blocks [3] Contraindications for Heparin:
• Active bleeding
• Major trauma
[3] Right side involvement should be suspected when:
• Inferior MI (elevated ST in leads II, III, AVF)
• Hypotension
[4] Additional questions to ask prior to cath lab arrival:
• CVA in last 6 months?
• Terminal cancer history?
• Any stomach ulcers or bleeding disorders?
• Recent surgery?
Approved by: Michael J. Kellum, MD, FACEP Date of Origin: November 2008
Date of This Revision:
83
Mercy Walworth EMS
Suggested Medical Guidelines
Stroke
Note:
Priorities Assessment Findings
Chief Complaint “Weakness”, “Confusion”, “Slurred Speech”, “Unresponsive”
OPQRST When did it start? Was it witnessed?
Associated Symptoms/
Pertinent Negatives
Headache, weakness, pupil dilation, slurred speech, aphasia, incontinent SAMPLE Medication consistent with history of stroke or TIA
Initial Exam ABC’s and correct any immediate life threats Detailed Focused Exam Vital signs: BP, HR, RR, Temp, SpO2
General Appearance: Unresponsive?, noticeable facial droop, drooling, slouched posture
Neuro: Cincinnati pre-hospital stroke scale (speech, facial symmetry, motor)
Data Blood Glucose
Goals of Therapy Maintain ABC’s and adequate vital signs Monitoring Cardiac rhythm strip
Heart rate and blood pressure
EMERGENCY MEDICAL RESPONDER/EMT
• Routine medical care
• Oxygen 2-4 LMP per nasal cannula, keep SpO2 > 90%
Give a status report to the ambulance crew by radio ASAP.
AEMT
• IV/IO 0.9% NS @ KVO
Contact Medical Control for the following:
• Additional Fluid Orders
INTERMEDIATE
• Consider intubation if unresponsive without gag reflex
• Complete Fibrinolytic screening (see footnote 1) Contact Medical Control for the following:
• Additional orders
PARAMEDIC
• Consider RSI; refer to Respiratory Distress Guidelines
• Notify Medical Control ASAP of results of Cincinnati Pre-hospital Stoke Scale Contact Medical Control for the following:
• Stable patients with persistent deficits may be taken directly to CT
• Is patient allergic to Fibrinolytic?
• Ever had fibrinolytic before? Which one?
• Is patient pregnant?
Approved by: Michael J. Kellum, MD, FACEP Date of Origin: November 2008
Date of This Revision:
85
Mercy Walworth EMS
Suggested Medical Guidelines
Submersion
Notes:
• RESCUER SAFETY IS #1. Many well-intentioned volunteer and professional rescuers have been injured or killed attempting to save a drowning victim.
• If the victim is still in the water dispatch local water rescue resources
• Submersion is a loss of consciousness under water
• Submersion is primarily a respiratory problem
• When delivering ventilations and chest compressions assume the patient will vomit. Be prepared to suction. Secure the patient’s airway as soon as possible.
• Any patient successfully resuscitated after a loss of consciousness underwater needs transport to the hospital and physician evaluation
Priorities Assessment Findings
Chief Complaint “Drowning”, “Near Drowning”
OPQRST Onset. Duration of time under water. Water temperature, if known. Bystander CPR performed? AED Used?
Associated Symptoms/
Pertinent Negatives
Alcohol involved? Trauma involved?
SAMPLE Allergies? Medications?
Initial Exam Check ABCs and correct immediately life-threatening problems.
Detailed Focused Exam Vital Signs: BP, HR, RR, Temp, SpO2
General Appearance: lifeless Skin: pale, cool, mottled Lungs: wet or clear?
Heart: Rate and regularity? Absent heart sounds?
Neuro: Unresponsive?
Data Blood sugar, EKG, SpO2.
Goals of Therapy Return of spontaneous circulation (ROSC) Monitoring BP, HR, RR, EKG, SpO2.
EMERGENCY MEDICAL RESPONDER
• Routine C-spine stabilization of all submersion patients is not indicated
• When a mechanism of injury (e.g. diving accidents), or obvious signs of trauma, is present:
o C-spine stabilization is indicated
o Open the airway with a jaw-thrust maneuver
o Ventilate the patient while maintaining C-spine stabilization o Remove the patient from the water on a long-spine board
• Always assume that hypothermia is present and follow the Hypothermia & Frostbite Guidelines
• Do NOT start CPR if the patient has been submerged for more than 1 hour
• If the patient is pulseless and not breathing, follow the Cardiac Arrest Guidelines o Remove the patient from standing water
o Dry the chest o Attach an AED
• If an upper airway obstruction is suspected follow American Heart Association Guidelines
o
Routine use of abdominal thrusts and back blows is not indicated in submersions Give a status report to the ambulance crew by radio ASAP.• IV Normal Saline @ KVO
• If hypotension is suspected, initiate a Normal Saline Bolus of 250 ml
• Warm the IV fluids and run at 250 ml/hr according to the Hypothermia & Frostbite Guidelines
• If Hypoglycemia is present, follow Hypoglycemia Guidelines
• If a narcotic overdose is suspected, follow the Toxic Exposure/Overdose Guidelines Contact Medical Control for the following:
• Additional orders
INTERMEDIATE/PARAMEDIC
• Consider endotracheal intubation Contact Medical Control for the following:
• Additional orders
FOOTNOTES:
• Adult Respiratory Distress Syndrome (ARDS) is very common in a near drowning victim. The onset is slow, but can be life threatening. Monitor ventilation status (SPO2, EtCO2 and lung sounds) often
Approved by: Michael J. Kellum, MD, FACEP Date of Origin: November 2008
Date of This Revision:
87
Mercy Walworth EMS
Suggested Medical Guidelines
Syncope
Note:
• Common causes of syncope include dehydration and vasovagal reflexes; less commonly syncope may result from arrhythmias and stroke
• Syncope and seizures both result in loss of consciousness. Both may occur with or without convulsions. In syncope, the convulsions are brief. Unlike seizures, in syncope the patient regains consciousness quickly and without the usual postictal confusion.
Priorities Assessment Findings
Chief Complaint “Passed Out”; “Fainted”
OPQRST Determine onset, duration and triggering events (e.g., freight, defecation, micturition)
Associated Symptoms/
Pertinent Negatives
Headache, dizziness, confusion, vomiting, diarrhea, dehydration, incontinence, seizure, lack of food or water
SAMPLE Exposure to known allergen. History of heart disease or stroke. Current or past medication for these problems. Compliance with these medications recently.
Initial Exam Check ABCs and correct any immediately life threatening problems.
Detailed Focused Exam Vital Signs: BP, HR, RR, Temp, SpO2
General Appearance: may be normal or ill appearing Skin: Pale, cool, diaphoretic
Heart: Hypotension, tachycardia, weak pulses, poor capillary refill?
Neuro: May be A&OX3; ALOC? Focal deficits, signs of trauma due to falling?
Data Blood glucose. EKG
Goals of Therapy Treat symptomatic bradycardia/hypotension.
Monitoring Cardiac Rhythm monitoring Heart rate and blood pressure
EMERGENCY MEDICAL RESPONDER/EMT
• Routine Medical Care
• Gently lower the patient to a supine position or Trendelenberg position if hypotensive.
• Oxygen 2-4 LPM via nasal cannula; Maintain SpO2 > 90%
Give a status report to the ambulance crew by radio ASAP.
AEMT
• Initiate IV 0.9%NS @ KVO
• If patient is hypotensive, or shows signs of dehydration (rapid heart rate) administer 250ml fluid bolus as long as lung sounds are clear
Contact Medical Control for the following:
• Additional fluid orders
INTERMEDIATE
• If still sinus bradycardia with a HR <40, consider Atropine Sulfate 0.5 mg IV
• If altered LOC or hemodynamically unstable, initiate transcutaneous pacing
• Consider pain management for transcutaneous pacing using Fentanyl 50-100mcg IV Contact Medical Control for the following:
• Persistent hypotension or bradycardia