2010 Cardiac Care Guidelines

Well, it is once again time for a new set of guidelines for basic and advanced cardiac care to be produced. This includes basic life suport, ACLS, PALS and NRP.
The changes have been fairly aggressive and directed at bettering well aimed basic life support. The advance life support guidelines have seen more of a schematic remodeling rather than intervention based changes. Rather than a top down approach, it seems to be circular in nature. Think, Act, Evaluate!

Our friend Dr Scott Weingart will discuss some of the changes with us here.

Podcast

http://blog.emcrit.org/?powerpress_pinw=823-podcast


Podcast Notes

http://emcrit.org/1-resus/new-acls-guidelines.htm

Scott talks about his podcast on intra arrest management in the above podcast, here it is for your reference.

Intra-Arrest Management Podcast

http://blog.emcrit.org/?powerpress_pinw=734-podcast

ABC is Now CAB

Here is the new way that CPR is done. As a health care professional, a pulse check is reqired before starting compressions.

C irculation

A irway

B reathing

We will be updating our clinical guidelines to reflect the changes. The role out will be April 1, 2011. Several folks from the primary and advanced care cadres will be steering the changes, along with clinical operations and the medical director.

Push Dose Pressors Get You Out of Pickles

Bolus dose pressors and inotropes have been used by the anesthesiologists for decades, but they have not penetrated into standard emergency medicine practice. I don’t know why. They are the perfect solution to short-lived hypotension, e.g. post-intubation or during sedation.
They also can act as a bridge to drip pressors while they are being mixed.

Our guidelines describe the use of push dose epinephrine in several instances, a well as the accompanying formulary. I think it is important to be familiar with the other push dose pressors as they may be used by practitioners in the ICU. Check out this pod cast and the accompanying notes by Dr Scott Weingarten.

Click Here for printable sheet with mixing instructions

POD Cast

http://blog.emcrit.org/?powerpress_pinw=76-podcast

Ephedrine

I don’t use this one much anymore, listen to the podcast to hear why.

Onset-Near Instant

Duration-1 hour

Mixing Instructions:
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe, draw up 1 ml of ephedrine from the vial (vial contains Ephedrine 50 mg/ml)
Now you have 10 mls of Ephedrine 5 mg/ml

Dose:
1-2 ml every 2-5 minutes (5-10 mg)

No extravasation worries!


Epinephrine

Do not give cardiac arrest doses (1 mg) to patients with a pulse
Has alpha and beta-1/2 effects so it is an inopressor

Onset-1 minute

Duration-5-10 minutes

Mixing Instructions:
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe, draw up 1 ml of epinephrine from the cardiac amp (amp contains Epinephrine 100 mcg/ml)
Now you have 10 mls of Epinephrine 10 mcg/ml

Dose:
0.5-2 ml every 2-5 minutes (5-20 mcg)
No extravasation worries!


Phenylephrine

Phenyl as a bolus dose is just the best! It is clean, quick, and never causes trouble.
It is pure alpha, so no intrinsic inotropy, but increases in heart perfusion can improve cardiac output.

Onset-1 minute

Duration- 20 minutes

Mixing Instructions:
Take a 3 ml syringe and draw up 1 ml of phenylephrine from the vial (vial contains phenylephrine 10 mg/ml)
Inject this into a 100 ml bag of NS
Now you have 100 mls of phenylephrine 100 mcg/ml
Draw up some into a syringe; each ml in the syringe is 100 mcg

Dose: 0.5-2 ml every 2-5 minutes (50-200 mcg)
No extravasation worries!

Basic Chest Radiography

Introductory Chest Radiography Interpretation

As critical care transport practitioners, a valuable skill to have in ones bag of clinical tricks is the ability to confidently analyse and interpret chest radiographs. With each health center in hospital now capable of digital imagery, there is tremendous benefit to being able to like your clinical assessment to the objective data found in the radiographic image.

Take a look at these videos in order to develop a solid and systematic approach to interpreting the data found in the image. Have fun.





Systematic Analysis 5 + 1

There are many different systems employed in the assessment of a chest radiograph. Despite the differences, each has a stepped approach so as to glean all of the important information contained in the image.




Here Are the Five + One Points to Add to Your References

1) Properly orient the image so the image is correctly displayed on the screen:
a) check exposure (spinus processes of first four vertabrae only seen)
b) patient position (medial ends of clavicles equi-distant from spine)


2) Divide the chest into three distinct lung zones and compare each side for:
a) lung tissue on each side of equal radiolucence
b) examine the apices's for symmetry and aeration
c) phrenic margins for crispness sharp definition
d) diaphragm for proper proportion (R diaphragm 1-1.5 cm higher than L)
e) inspect the hilar vessels (L higher than R)
f) identify the trachea and assess for deviation

3) Cardiac silhouette
a) measure cardiothoracic ratio (L + R cardiac border= <1/2> )

4) Inspect the bones
a) study each side of chest for bone symmetry and attachment
c) visualize each joint for proper positioning

5) Inspect the soft tissue
a) presence of swelling
b) symmetry between sides of chest

Plus 1) Assess for tubes and lines

a) what type of tube or line

b) right place, position and use





Remember that radiography is all about perspective and like a fine piece of art on the wall, it must be viewed from various distances and angles to be best appreciated.

Now Lets See Some Examples

Dr A. J. Chandrasheker, specialist of internal medicine in Louisiana, will guide us through progressively more pathological radiographic images and break down what is seen and not seen.

By applying a consistant approach to reading radiography films, and reading every one you can get your hands/eyes on, will help you link your assessments into the broad diagnostic picture. Again, all of the health facilities across the Yukon will be digital by October 2010, allowing for better diagnosis and consult for every patient.

Basic Mechanical Ventilator Management

Introduction

Quite a few folks have been asking for baseline ventilator management theory and practice. Many of the resources out there are rather stuffed with complex theory that can lead a practitioner to achieve non-pharmacologic conscious sedation. The following is a collection of two podcasts from Dr Scott Weingarten on this subject that are well done. I like Scott's approach to both mechanical ventilation and bringing the care from upstairs in the ICU into the ER.

I will include a video segment on how use the information presented with the LTV 1000 once I learn how to create video files on my camera.

Dominating the Vent Part 1

EMCrit Lecture - Dominating the Vent: Part I from Scott from EMCrit on Vimeo.

Dominating the Vent Part 2

Dominating the Vent Part II from Scott from EMCrit on Vimeo.

Bellow is the handout described in the pod casts

http://blog.emcrit.org/wp-content/uploads/vent-handout.pdf

Airway Management Tutorials

Introduction

Yukon EMS Medevac Wing utilizes a varied armamentarium of airway management tools in order to maintain or restore oxygenation and ventilation in the patients we care for. The following is a series of tutorials collected for the purpose of augmenting the information presented in the skills section of the YEMS clinical guidelines. Also featured will be clinical pearls designed to augment practice in the lab setting as well as in the field.

Basic Airway Management

The foundation of advanced airway management is solid basic life support skills. The recognition of respiratory failure or arrest and intervening without delay, can mean the difference between stabilization and deterioration. An ability to competently manipulate the airway, place airway adjuncts and deliver effective positive pressure ventilation's with a bag valve mask, will buy the patient time until advanced equipment can be readied and applied.



The following are pearls specific to our program:

• Test the BVM for proper functioning during routine equipment checks.




• Mentally visualize location of equipment so that when it is require it can be obtained without thinking.




• Practice the skill on the airway management trainer and/or Stat Man regularly.

Subglottic Rescue Airways

The two subglottic rescue airways used by YEMS Medevac wing are the King LTD and the LMA. The LMA is only carried in the flight bag, whereas the King LTD is carried in both the ALS and BLS ground jump bags. Practitioners are to become equally familiar with each device, yet expect to use the King LTD for the majority of times where a rescue airway is necessary. The use of the LMA is a device employed for the pediatric population because the King LTD has a patient size limit of 4 ft or greater.

The rescue airway is to be employed by the ALS practitioner after a failed endotracheal attempt has occurred, or a a primary ventilation device when the use of a BVM and airway adjunct is impractical due to space or has failed due to failure to maintain an appropriate mask seal.




Additional Points:

• Place the instruction card on the patients chest in order to assist in remembering the sequence of steps in applying the device.




• Remember to auscultate lung sounds and assess chest rise and fall to confirm adequacy of ventilation.




• Unless time is a factor (such as in the case of cardiac arrest), use the commercial Stabletube securing device instead of tape to secure the device externally.

Additional Points:

• Only one finger should be used to place the LMA in smaller pediatric patients




• All of the same indications and contraindications apply to the LMA as to the King LTD




• Secure the device withe the Stabletube securing device or tape after primary and secondary confirmation has been completed

Both of these devices can be exchanged with an endotracheal tube with the aid of a Bougie inserted into the lumin of the devices and advanced into the trachea. (more on this later)

Suctioning Subglottic Airways

Here is a demonstration of how to do this. You might know who the presenter is for this video.

Endotracheal Intubation

The following is a graphic example of the peformance of larygoscopy and endotracheal tube placement. It is meant to enhance your baseline knowledge of the skill and not as an end in itself. Completion of the forthcoming airway package is necessary in order to understand all of the equipment and assessments required prior to passing the tube.



Now that the procedure has been shown, check out the anatomy and landmarks that you have read about on a cadaveric model. Thanks Airwaycam!

In order to better visualize the landmarks and achieve an optimal view of the tracheal inlet, let us take a look at bi manual laryngoscopy.





The Bougie (trach tube introducer)

Another practical device that is carried in both the ground and flight bags is the bougie or trach tube introducer. First demonstrated as a device for the cure for intractable ciphilus in the male patient, in the 19th century, the device became an adjuct for the intubation of the difficulty airway in the 194os. The bougie can be a useful adjunct for the difficult airway or when the clinician needs to replace a rescue airway with an endotracheal tube.




Cricothyroidotomy

As a tertiary airway that our program carries is the Cook Melkar Crikothyroidotomy Device. Utilizing the Seldinger Techneque, the device minimizes the risk of blind space canulation and laceration of the great vessels.

Baby Pod II Infant Transport

To accommodate the size and special needs of an infant during transport, Yukon EMS Medevac Wing uses a Baby Pod. (See photo). A Baby Pod is a transport incubator specially designed to safely and comfortably transfer 2-8kg infants from one facility to another.

The Baby Pod II comes with shock absorbent foam which eliminates vibrations during transport and a vacuum mattress that conforms to the infant’s shape, limiting unwanted movement.

The device utilizes the TransWarmer® Infant Transport Mattress to maintain a consistant micro environmental temperature throughout transport. This mattress is gel-filled and thermostable providing up to 2 hours of warming when cold stress is a concern.

The unit contains one TransWarmer® mattress, one set of securing straps, extra flannel blankets, a infant hat, an NRP resuscitation kit and neonatal non invasive monitoring electrode setup. The device will be taken on all obstrical transports where the mother is greater than 24 weeks gestation and/or there is a need to transport an infant less than one month of age (age corrected).

When the pod is properly secured to the #9 or #35 stretcher(s), it is able to withstand sizable acceleration/deceleration forces. Watch the video bellow to better understand the securing process.

http://www.babypod.com/videos/ct1hi.wmv

Hartwell Vaccuum Mattress

The Hartwell vaccuum mattress is the only device vaccuum style immobilization device approved by Yukon EMS as a stand alone spinal motion restriction device. The medevac program utilizes this device for long term spinal motion restriction in the transport setting.

In order to facilitate the positioning of the patient on and off this device, a clamshell style stretcher should be utilized.

In order to promote maximum comfort, a blanket roll should be placed under the knees and the thermorest mattress, covered with a "fluid proof blue sheet", placed between the patient and the device. The packaged patient can then be placed in a sleeping bag or blanket pack and positioned onto a Ferno #9 stretcher.