Ambulance Emergency Assistants (AEA)

43 Pages·2015·1.97 MB·English

Ambulance Emergency Assistants (AEA) CPD Activity for 2015

Activity: E1 (15)

General Theme: Clinical

Topics:

Do not underscore the value of a trauma assessment

Consider All Differentials for Respiratory Distress
Learn the signs and symptoms of acute angle closure glaucoma
Syncopal episodes can warn of cardiac conditions

Timely Prehospital Management of Stroke Victims Crucial for Patient
Be Wary During ECG Analysis in the Geriatric Population

To the Hospital or Not? Debating How to Handle Out-of-Hospital Cardiac Arrest
Non-invasive Positive Pressure Ventilation an Alternative to Intubation?

Approved for (4) Clinical Continuing Educational Units (CEU’s)

1
Don’t Underscore the Value of a Trauma Assessment

Fran Hildwine, BS, NREMT-P, CCEMT-P | From the October 2014 Issue | Wednesday, October 1, 2014

At 4:12 p.m. on a sunny summer day, Ambulance 5 is dispatched for a “sick person.”
Dispatch notes advise the patient is a 25-year-old male who’s had abdominal pain for two
days. While responding to the initial dispatch, the police radio crackles with an officer
requesting paramedics to expedite to a motor vehicle crash involving a motorcycle. The
location of the crash is three blocks ahead, directly in your path to the initial dispatch.
As you approach the scene you notice police have the road blocked and are frantically
waving you down to treat the seriously injured motorcyclist. You notify the 9-1-1 centre
you’re on location with police and request the next due BLS ambulance be dispatched to
your initial call.
Police direct you to an area of high grass behind the guardrail, where you find the 34-year-
old helmeted male, whose motorcycle struck the driver’s side of a small, two-door car,
ejecting him from the bike and over the car, where he struck the guardrail with his left side
and landed in the grass.
As you approach the supine patient you notice a severely angulated left arm and left leg and
immediately think, “This isn’t going to be good.”
Expecting the worst, you’re surprised to find an adequate respiratory effort at a rate of 24
as you kneel by the patient’s head in order to quickly stabilize the C-spine before calling out
to the patient to check responsiveness.
“Hello! Can you hear me?” you ask.
“Yeah,” he groans. You’re again amazed; he’s awake, alert and fully oriented to person,
place, time and events. He tells you he was driving the posted 40 mph speed limit when the
car pulled out in front of him. Police confirm this with a statement from the driver of the
car.
At the risk of sounding stupid, you ask him what hurts. “Everything!” he replies. “Is my leg
still there?”
Your rapid trauma assessment reveals cervical point tenderness in the area of C-5. His pupils
are equal, round and reactive, and he has equal chest expansion with full, clear breath
sounds. His abdomen is soft, non-tender and his pelvis is stable. His right arm is intact with a
radial pulse of 124 and you notice his right thigh is swollen and tender with crepitus
indicative of a femur fracture, but you do note distal pulse, motor and sensation.
The extremities on the left side are much worse. The left arm has multiple open fractures
with profuse bleeding and you can’t feel a distal pulse. His left leg has a deep laceration
from the knee to the hip with the fascia of the muscle clearly visible. His left foot is severely
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angulated, positioned roughly adjacent to the left knee, with multiple open fractures of the
tibia and fibula. You can’t feel distal pulses and are worried that any movement may cause
the few threads of tissue connecting the foot to tear and the foot to fall off.
At this time ALS arrives on scene, quickly eyeballs the patient and begins to set up the
ambulance while your crew finishes packaging the patient.
Prehospital Treatment
Your partner and police assist in cutting away the patient’s clothes while you secure a C-
collar. Another member of your crew quickly places trauma dressings over the gaping
wounds and positions the backboard. The log roll allows you to examine the spine and
you’re surprised to find no further injuries.
The patient is secured to a backboard, a cervical immobilization device is applied and the
patient is transferred to the ambulance. You place a non-rebreather mask on him with O2 at
15 Lpm while your partner obtains a blood pressure of 96/60. The paramedic supervisor
says she’ll notify the trauma centre. During the four-minute transport to the Level 2 trauma
centre ALS initiates a 14-gauge large bore IV in the right antecubital fossa and infuses a 500
cc fluid bolus. You continue to dress the wounds to the patient’s left extremities and
actually manage to obtain a SAMPLE (signs and symptoms, allergies, medications, past
history, last meal, events leading to injury) history.
Hospital Treatment
The trauma team is awaiting your arrival and quickly transfers the patient to a trauma
resuscitation bed. After quickly confirming your SAMPLE history, the anaesthesiologist uses
rapid sequence intubation to paralyze and sedate the patient in order to pass an 8.0
endotracheal tube and secure
his airway.
The trauma team completes its primary assessment, places a large bore femoral line and
begins rapid transfusion of three units of blood. This causes a rise in blood pressure that
reveals three small lacerations to the left brachial artery, which is now clearly visible.
A Combat Application Tourniquet is placed high on the left humerus and the bleeding is
controlled. The left arm and left leg are quickly bandaged and splinted before taking the
patient to get a CT scan then directly to the operating room.
The CT scan confirms the C-spine X-ray that shows a compression fracture of C-5 without
neurological impairment. Initial surgeries included a below-knee amputation of the left leg,
vascular repair of the left arm, external fixation of the left arm and placement of a halo
brace for the C-spine fracture.
The hospital and rehabilitation stays were lengthy, but uneventful. Six months later the
patient walks into your station to thank you and the crew for saving his life.
Discussion
There’s a very good reason trauma assessment is taught as a skill that needs to be
completed the same way every time. Deviation from standard trauma assessment during
Advanced Trauma Life Support (ATLS), which is mirrored in Prehospital Trauma Life Support
(PHTLS), provides an opportunity for important findings to be missed.
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The primary assessment of airway, breathing, circulation, disability and exposure addresses
the most life-threatening issues in order of importance and also provides an easy-to-
remember standard that serves to minimize mistakes. This patient had a potentially life-
threatening cervical spine fracture. Had the first arriving ambulance crew not taken the
precautions to protect the C-spine while they progressed through the primary assessment
this patient may not have survived.
EMTs and paramedics also need to acknowledge the impact of distracting injuries. It’s easy
to internalize the pain upon seeing a grossly deformed arm and leg, to get tunnel vision and
hyper-focus on these injuries. The reality is that extremity trauma is rarely life-threatening.
Most haemorrhage from extremity fractures can be treated with direct pressure and, in
extreme cases such as this, a tourniquet.
An organized, thorough and rapid secondary assessment assures that severe, possibly life-
threatening injuries are found and treated. Although there’s often some variation among
EMS and medical professional with the assessment of a medical patient, trauma
assessments are generally done head to toe in order to provide consistency of results.
Field treatment for the multisystem trauma patient needs to be focused on addressing life
threats, stabilizing the C-spine and rapidly transporting to the appropriate facility. Due to
the short scene and transport times, pain management wasn’t a factor in this case.
Lastly, does your department have a policy on how to address the need to triage calls when
presented with a life-threatening situation while responding to a different initial call? Some
departments require you to proceed to the initial dispatch, others allow you to stop if you
make sure a back-up unit is dispatched to the initial call for which you were responding.
Conclusion
This case illustrates how trauma care is a team effort. Every person who touched this
patient contributed to the successful outcome of this case. From the first police officer on
scene, to the EMTs, paramedics, trauma physicians, nurses, radiology technicians, operating
room staff, shock-trauma ICU, rehabilitation personnel and many others, there were many
opportunities for a poor outcome, but when we do what we do well, every time, we can rest
assured that these results are the norm. jems
Resource
Dickinson E, Politis J. Painful distractions: The importance of splinting and managing the pain
associated with fractures. JEMS. 2011;36(1):50–57.

4
Consider All Differentials for Respiratory Distress
Wes Ogilvie, MPA, JD, NRP, LP | From the November 2014 Issue | Friday, November 7, 2014

At 11:52 p.m., the county sheriff’s dispatcher tones out Medic 41 to an address in a rural
subdivision about 15 miles from their small town’s EMS station. Dispatch advises an out-of-
breath male is in the back bedroom and may not be able to unlock the front door. Since the
fire department doesn’t have any trained EMS providers, dispatch also assigns a sheriff’s
deputy to the call in the event the EMS crew needs to force entry to the house.
The crew arrives at the address almost the same time as the deputy. There appear to be two
houses on the property, both with the same address. The medics and deputy knock on the
door of the larger house, whose resident states she didn’t call 9-1-1. The medics and deputy
knock on the locked door of the second house but receive no response. The deputy forces it
open.
The EMS crew makes it to the back bedroom of the home, where they find an approximately
70-year-old male in a tripod position at the foot of his bed. He’s breathing with the aid of a
nasal cannula on a home oxygen generator at a rate of two litres per minute. The patient
gasps for breath between each word as he tells the crew, “Can’t … breathe!” The patient
weighs approximately 330 pounds.
Prehospital Treatment
The paramedic immediately auscultates the lungs and hears little air movement. His EMT
partner hooks the patient to the capnography and pulse oximetry functions on the cardiac
monitor and then transfers the patient’s oxygen to their oxygen cylinder. Due to the
confined quarters of the residence, the crew was unable to bring the stretcher inside.
The cardiac monitor shows a heart rate of approximately 94 in a sinus rhythm, a blood
pressure of 104/48, and a pulse oximetry of 86% while on the oxygen at four litres per
minute. The capnography waveform is normal.
The patient’s wife is able to provide some of the patient’s prior history, including several
previous heart attacks, chronic obstructive pulmonary disease, hypertension and congestive
heart failure (CHF). She also provides a list of his medications, which include lisinopril with
HCTZ (hydrochlorothiazide), nitroglycerin, albuterol, Advair (fluticasone) and simvastatin.
She says her husband has been ill for several days and hasn’t been compliant with his
prescription medications for the past three days. He went to the back room to see if he
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could sleep sitting up and told her not to disturb him. In fact, she didn’t know he called for
EMS assistance.
In part because of the critical nature of the call, the size of the patient and the difficulty in
accessing the back bedroom, the crew contacts dispatch by radio and requests additional
personnel. Shortly after the tones go out, a volunteer first responder and an off-duty
paramedic who lives in town are en route.
Meanwhile, the paramedic asks his partner and the deputy to get the continuous positive
airway pressure (CPAP) kit and a stair chair. While this is occurring, the paramedic turns the
oxygen flow up to 15 litres per minute by nasal cannula for passive oxygenation and
prepares for a possible emergent intubation. As the team begins assembling the CPAP
device, the two additional responders arrive and the team manoeuvres the patient onto the
stair chair to move the patient to the ambulance.
The providers move the patient to the stretcher. At this point, the patient’s head is
beginning to bob and he seems to be confused and lethargic. Both paramedics agree that
the patient’s level of consciousness is insufficient to maintain compliance with CPAP therapy
and agree that a crash airway situation exists.
They ask the EMT to get the video laryngoscope, connect the powered suction, obtain a
rescue airway from the shelf and pre-oxygenate the patient. As one of the paramedics
prepares the laryngoscope, the other draws up the appropriate rapid sequence intubation
medications per protocol: 450 mg of ketamine (3 mg/kg at 150 kg) and 150 mg of
rocuronium (1 mg/kg at 150 kg). He also prepares 5 mg of midazolam per protocol.
After both medics confirm the medications and dosages, the second establishes IV access
via an 18-gauge catheter to the left forearm. After pre-oxygenating the patient, the other
paramedic administers the ketamine, then the rocuronium. He uses the video laryngoscope
to pass a 7.5 mm endotracheal (ET) tube and captures the image of the tube passing
through the vocal cords onto the digital memory card. They then confirm placement via
waveform end-tidal carbon dioxide capnography and secure the tube with a commercial
device. Next, the patient is sedated with midazolam. The two paramedics agree they should
both attend to the patient and ask the EMT to initiate emergency transport to a large
community hospital on the outskirts of the nearest large city, about 35 miles away.
En route, the patient’s condition remains relatively unchanged, especially since he’s been
sedated. The crew also obtains a 12-lead ECG, which doesn’t reveal any acute ST segment
changes. The relative hypotension, especially in consideration of previous patient
encounters where he’s routinely noncompliant with his anti-hypertensives, cause both
providers to rapidly eliminate the possibility of a CHF exacerbation and thus rule out nitrate
or diuretic therapy. The primary paramedic also obtains an axillary temperature of 103.5
degrees F. Based on this, combined with the patient’s relative hypotension, the paramedics
suspect the possibility of sepsis and begin administering a fluid bolus. They contact the
hospital via radio and advise the hospital of their treatment and the possible concern of
sepsis, requesting that the hospital have a respiratory therapist in the ED on their arrival.
Hospital Treatment
The patient is brought into the primary resuscitation room where the emergency physician
on duty evaluates the patient. A chest X-ray is ordered for confirmation of ET tube
placement. Upon viewing the film, the physician determines the patient has pneumonia. A
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dosage of Levaquin (levofloxacin) is ordered via IV pump along with several fluid boluses.
The patient remains on the ventilator and is admitted to the intensive care unit. After a
course of antibiotic therapy, the patient is weaned from the ventilator and returns home
several weeks later after discharge from the hospital to a skilled nursing facility for
rehabilitation.
Discussion & Clinical Pearls
Pneumonia is a relatively common but overlooked cause of respiratory distress. Pneumonia
is a lung infection that causes fluid to collect in the alveoli of the lungs. It causes
inflammation, which may cause dyspnoea, fever, chills, chest pain, chest wall pain or
coughing.1
Several key clinical points bear mentioning. First, the entire EMS team practiced crew
resource management throughout the course of the call. The initial crew recognized the
need for additional personnel for both patient movement and patient treatment. The
assisting first responder recognized the patient’s condition had deteriorated to the point
where CPAP was contraindicated. Both paramedics recognized the patient’s condition might
require both of them to attend to the patient during transport and they additionally worked
together as a team, particularly during the rapid sequence intubation.
Also, while treating the patient, the providers used passive oxygenation with the nasal
cannula to boost the patient’s oxygen saturation prior to intubation. The nasal cannula can
even remain on the patient during the intubation attempt to maintain oxygen saturation.
High-flow oxygen through the cannula has been shown to maintain saturations in excess of
95% during intubation.2
Finally, the EMS team identified the possibility of sepsis when they obtained the patient’s
temperature and noted the relatively low blood pressure (particularly for a patient with a
history of hypertension).
Conclusion
This case presented challenges in assessment and diagnosis, especially considering the
patient’s history of respiratory diseases and possible other comorbidities. Even with
obtaining the patient’s history from the patient, family, and his medications, several likely
differential diagnoses exist. The use of waveform capnography can help rule in or out the
possibility of a reactive airway disease process. This case also illustrates that, even in a
patient with a history of several respiratory disease processes, a new cause of respiratory
failure can occur. Again, like any form of medicine, clinically competent and progressive
emergency medical care is dependent on a through physical assessment and history-taking.
References
1. Abrahamson L, Mosesso V Jr., editors: Advanced medical life support: An assessment based approach. Elsevier Mosby: St. Louis, Mo.,
pp. 124–126, 2011.
2. Levitan R. (Dec. 9, 2010.) No desat! Emergency Physicians Monthly. Retrieved July 11, 2014,
fromwww.epmonthly.com/archives/features/no-desat-/.

7
Learn the Signs & Symptoms of Acute Angle Closure
Glaucoma

Judy Torres, BFA, JD, NREMT-P | From the October 2013 Issue | Tuesday, October 8, 2013

Patients with trauma to the eye should have their eye bandaged as appropriate to protect from additional
damage. Also, whenever bandaging one eye, cover/bandage the other eye to reduce tandem eye

movement.

Key Terms

Aqueous humor: The watery fluid that bathes and nourishes the anterior part of the eye.
Ciliary body: The part of the eye above the lens that produces aqueous humor.
Cornea: The outer transparent structure that covers and protects the iris and pupil.
Choroid: A layer of the eye behind the retina that contains the blood vessels that supply the
retina.
Iris: The colored tissue behind the cornea that regulates the light entering your eye by
changing the size of the pupil.
Lens: The clear part of the eye which is suspended behind the iris.
Optic nerve: A bundle of nerves located in the posterior eye that carries messages from the
retina to the brain.
Trabecular meshwork: The spongy tissue near the cornea. This is where the aqueous humor
flows out of your eye.

Decision-making by paramedics in the field has the potential to become a challenging
situation. The decision of whether to transport has to be made quickly and efficiently. It
often becomes a collaborative effort among the responding unit, the patient and their
family members or friends. Insufficient information related to the actual complaint and
limited access to the patient’s past medical history can also contribute to on-scene
confusion. Balancing the patient’s care, safety and patient choice can sometimes be
overwhelming.
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When confronted with a patient who has one or more complaints that range from blurred
vision and seeing halos around lights to severe eye pain and vomiting, time is of the
essence.
This article discusses the classic signs and symptoms of acute angle closure glaucoma and
will help you make critical transport decisions and understand available treatment options
when faced with making a choice that could save someone’s vision.

What Is It?
Acute angle closure glaucoma (AACG), sometimes called acute narrow angle glaucoma or
acute closed angle glaucoma, is a true medical emergency. Rapid and immediate treatment
is necessary to prevent optic nerve damage and permanent loss of vision, which can occur
within hours without prompt and appropriate treatment.
AACG is caused by a rapid or sudden increase in pressure inside the eye or intraocular
pressure (IOP). This typically happens when the iris is pushed against the trabecular
meshwork (the spongy tissue located near the cornea where the aqueous humor flows out
of the eye) or drainage channels, and the fluid or aqueous humor (the watery fluid that
nourishes the interior of your eye) that normally drains out of the eye is blocked. This
creates the increase in IOP. (See Figure 2, p. 44.)
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Acute angle closure glaucoma sometimes presents with moderately dilated and
nonreactive pupils. Photos Matthew Strauss

Keep in mind that there are four main types of glaucoma: open angle or chronic glaucoma,
AACG, congenital glaucoma and secondary glaucoma. Secondary glaucoma can be open or
closed. The disease is considered acute and requires immediate care if the angle closes
suddenly rather than gradually or intermittently.
Treatment for AACG includes laser trabeculoplasty, which is a modification of the trabecular
meshwork, and iridotomy, which is the making of small holes through the iris without the
removal of tissue.
An iridectomy, which involves the actual removal of iris tissue, can be done with a laser or
by surgical means. A laser beam (either an argon laser or neodymium-doped yttrium
aluminum garnet [Nd:YAG] laser) creates a hole in the iris to relieve the pressure so the
aqueous humor can drain from the posterior chamber of the eye to the anterior chamber.
The Nd:YAG allows for a newer technique that can actually target specific cells in the
trabecular meshwork and can cause less damage than the argon laser.

Signs, Symptoms & Treatment
The signs and symptoms of AACG can be dramatic. Field providers may be presented with a
distressed patient complaining of severe pain around the eyes with blurred vision. They may
be seeing colored haloes around lights, have profuse tearing and redness, nausea and
vomiting, abdominal discomfort, and a headache and/or brow ache.
Taking time to examine your patient’s pupils may reveal moderately dilated and nonreactive
pupils. The patient may also have nerve damage. These signs and symptoms will usually be
sudden or acute and constant in nature. Many times only one eye is affected (uniocular) but
AACG can affect both eyes.1
The recommended immediate treatment is to reduce the intraocular pressure as soon as
possible. Your objective would be to get the patient to the ED as soon as possible, providing
supportive measures (e.g., IV, O2, monitor, position of comfort, and rapid transport) en
route to the hospital.
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