Week 5 - Intro to RSI

Week 5 – Introduction to RSI

RSI, or Rapid Sequence Intubation, is the process of chemically paralyzing someone so that they can be intubated to protect their airway.  This technique couples sedation to induce unconsciousness (induction) with muscular paralysis.

Below is a link to a podcast done by Dr. Jeffrey Guy who is a professor of surgery and director of the burn center at Vanderbilt University School of Medicine.  Please listen to the podcast and then answer the questions that are listed below.  

Link:

http://cl.ly/0F0R3v2F322k30450G1p

Practical Exercise

1.     What does Dr. Guy say are the key components that are listed to this technique:

a.    Short acting Barbiturates and muscular paralytics

b.    Provider knowledge and proper equipment

c.     GCS < 8 and supporting MOI

d.    Proper medications and supporting protocols

2.     RSI has three goals.  Which of the following is not a goal of RSI:

a.    Overcome potential barriers of intubation;

b.    Provide protection to normal physiological responses to intubation;

c.     Provide humane conditions;

d.    Increase and stabilize vital signs in traumatic patients.

3.     3. What is the different in goals between Rapid Sequence Induction and Rapid Sequence Intubation?

4.     Before administration of the drugs to perform an RSI, which equipment is NOT necessarily required to be nearby and ready:

a.    Functional suction and O2 supply;

b.    Functional laryngoscope;

c.     Medical Control authorization;

d.    End tidal CO2 and pulse oximetry

5.     What are some anatomical problems that could interfere with an ability to provide ventilations via BVM to the patient?

a.    Cold sores or snoring respirations;

b.    Dentures or Hemiglossectomy;

c.     Facial hair or facial trauma;

d.    Cleft lip or cleft palate

Week 4 - Respiratory Distress

Week 4 – Respiratory Distress

Respiratory distress is a common finding in many patients who call for EMS. There can be many causes including dyspnea, hypoxia, hypercapnia and cyanosis. Despite any fancy tests that can be performed on a patient, the evaluation of respiratory distress depends on careful history and physical examination of the patient. Discussed below are three commons causes of respiratory distress, along with the potential causes of each.

Dyspnea
Dyspnea is the subjective finding of difficult, labored or uncomfortable breathing. There is no single mechanism that causes dyspnea, however most patients will have a cardiac or pulmonary cause.

Common causes include obstructive airway, asthma, COPD, CHF, Unstable Angina/MI and Pneumonia. The most immediately life threatening causes include upper airway obstruction, tension pneumothorax, pulmonary embolism, neuromuscular weakness, and Gullian-Barre syndrome.

Hypoxemia
Hypoxemia is the inadequate delivery of oxygen to the tissues. Oxygen delivery is mainly a function of cardiac output, hemoglobin concentrations and oxygen saturation. Hypoxemia typically results from a combination of five distinct mechanisms:

Hypoventilation hypoxia in which lack of ventilation increases PaCO2, thereby displacing it from the alveolus and lowering the amount delivered to the alveolar capillaries;
Right-to-left shunt in which blood bypasses the lungs, thereby increasing the amount of unoxegenated blood entering the systemic circulation;
Ventilation/perfusion mismatch in which areas of the lung are perfused but not ventilated;
Diffusion impairment in which alveolar-blood barrier abnormality causes impairment of oxygenation;
Low inspired oxygen, typically occurring at high altitudes.

Hypercapnia
Hypercapnia is defined as a PaCO2 above 45 and is exclusively due to alveolar hypoventilation. Factors that affect alveolar ventilation include respiratory rate, tidal volume and dead space volume.

Signs and symptoms can depend on the rate of change and the absolute value of PaCO2. Acute elevations result in increased intracranial pressure, which causes patients to complain of a headache, confusion and lethargy. In severe cases in which the PaCO2 acutely rises above 80, coma, encephalopathy and seizures may be present.


Practical Exercise
1. Your patient is a 35 year old female, who called EMS stating that she was having some difficulty catching her breath. Vital signs are within normal limits, and your assessment reveals that patient is complaining of some nausea and a headache. She is also sluggish to answer your questions.

2. What do you suspect this patient could be suffering from and why?
While performing your assessment, what are some ways you could distinguish between Hypoxemia and Hypercapnia?

3. What would your treatment plan include for the above referenced patient?

Patient Assessment - Week 3

Patient Assessment – Week 3

Knowing how to perform a patient assessment is one of the most vital tools of the Paramedic.  It helps you to answer vital questions like who, what, when, and how about the patient and the surrounding scene. No matter the call, no matter the patient, the EMS provider needs to be able to rapidly zero in on a complaint, make a working diagnosis, and provide adequate treatment for the patient’s condition.  If you don’t know what is going on with the patient, how are you going to provide them with adequate treatment?

Below are some tricks that you can use to ensure you are performing a great assessment:

1. Just Do It! – Remember, you can’t over-assess your patient. The more information you get the better. Every patient gets a full assessment, every time. Even if you can’t act on the information you gather, the information could prove invaluable to healthcare providers further down the road. They need good information on the acute phase of the patient’s illness. Remember, the Paramedic is “the eyes and ears of the physician in the field.”

2. Standardize! – Develop your own version of the standard assessment and do it every time.  Think up a set of questions you want to know the answers to about your patient, and answer them every time. Not only will practicing the assessment get it down to a science, you’ll also get very quick at it.  Me personally, I take a temperature and blood glucose on every patient I come into contact with.  Other information such as last tetanus shot, last flu shot, last menstrual period and pts primary doctor will make your own and the receiving facilities report writing much easier. 

                                                    

3. Start your assessment the second you arrive on scene – Start gathering information about the patient immediately.  The assessment should be performed constantly and not just at any one specific point in your contact with the patient.  It should be performed multiple times based on the changing condition of your patient. 

4. Check THESE THREE THINGS when you first encounter the patient – Always introduce yourself to the patient using your name and while you’re doing this, feel their radial pulse with your fingers. This tells you three immediately important things that will drive the rest of your care: The status of their Airway, Breathing, and Circulation. You’ll feel the rate and quality of their pulse; feel their skin temperature, moisture, and condition; and be able to assess their work of breathing when they answer you back from your introduction. If any of these things are compromised then the patient is probably sick and in need of intervention.

5. Try to determine the patient’s ultimate diagnosis – As you progress through the Paramedic class, your knowledge of the body and the various systems within it will increase dramatically.  All of this instruction is so that you can make your own field diagnosis, so that you can start treatment and interventions that could potentially save the patients life.  EMS is an extension of the doctor’s treatment, and most of the time we are the first step in a much longer process.

  

6.     Don’t afraid to touch the patient – You’re a medical person. Medical people touch other people. Sometimes they see them naked. Sometimes it’s uncomfortable and sometimes you have to touch them in a way that wouldn’t otherwise be socially acceptable. Of course, don’t do anything wrong, illegal, or immoral… but when you’re checking for a broken leg you have to touch the leg. Actually look at, listen to, and feel your patients, but always maintain your professionalism. 

Practical Exercise

Start writing your own patient assessment form, and share with me some questions you would want to ask your patient during your assessment.  Provide some insight, whether it is book knowledge or practical field knowledge, which causes you to want to ask those questions.