EMS: the tools we use

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  1. 1. A N D H O W N O T T O G E T U S E D B Y T H E M . The Tools we use
  2. 2. RULE No. 1 Tools supplement clinical thinking and details subjective and objective assessments, they do not replace them. AKA: Treat the patient, NOT THE MONITOR (or the glucometer, or the pulse ox)
  3. 3. RULE No. 2 Tools fail if you: Dont take care of them Dont check them out EVERY SHIFT Dont know how to use them Dont know how to NOT use them Dont read about the technology behind them AKA: Murphy is a son of a bitch waiting to screw with you and your equipment.
  4. 4. What we will cover Stethoscope Sphygmomanometer Glucometer SPO2/SPCO EKG ETCO2
  5. 5. Stethoscope
  6. 6. Stethoscope Prior to the advent of the stethoscope, there were no reliable, non-invasive (and therefore non-lethal) methods to assess certain parts of the human anatomy.
  7. 7. A Stethoscope is used by Auscultation (listening) Sound is simply interpretation of vibrations by the specialized nervous system structures that send data to the brain. Therefore any method that limits outside vibration and noise will increase the fidelity of auscultation Position to the patent Length and thickness of tubing on stethoscope Heels off ground in moving ambulance Environmental factors
  8. 8. Auscultation
  9. 9. Auscultation 1 1 2 2 3 3 A 4 4 5 5 6 6 H
  10. 10. Variations Electronic Recording Duo-stethascope (for teaching) Fetoscope, AKA A Pinard Horn
  11. 11. Sphygmomanometer Rev. Stephen Hale's experiments to determine the blood pressure of a horse. Circa 1733
  12. 12. Sphygmomanometer When we talk about blood pressure, we are usually speaking of Non-Invasive Blood Pressure (NIBP). This is used to estimate the Mean Arterial Pressure (MAP) and thus estimate Aortic Pressure.
  13. 13. Key Point: Blood Pressure (NIBP) is an indirect estimate of central perfusion pressures
  14. 14. Blood Pressure (NIBP) Two basic types Manual Mercury Aneroid Automatic
  15. 15. Blood Pressure (NIBP) Systolic Diastolic Mm Hg Pulse pressure MAP
  16. 16. Pulse Pressure Generally speaking it is the pressure that produces a pulse that we can feel. Specifically it is pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. SBP DPB = Pulse Pressure Significant for: A PP is considered LOW if it is less than 25% of the SBP. A narrowing PP is significant for progressing cardiac tapenade, blood loss, or Tension Pneumothorax A high PP is significant for cardiac disease, HTN, and cor pulmonale
  17. 17. Mean Arterial Pressure The MAP is an mathmatical estimate of the current perfusion pressure. A minimum MAP of 50-60 mmHg is needed for most perfusion sensitive organs. Two main methods of calculation: Diastolic pressure + one third of the patients pulse pressure: diastolic blood pressure + (pulse pressure/3). Diastolic pressure times 2 plus the systolic pressure and then divide that number by 3: (diastolic pressure x 2) + systolic pressure] / 3 Normal MAP is between 70110 mmHg A normal MAP does not preclude a serious condition
  18. 18. Orthostatic Blood Pressure Procedure: Assess the need for orthostatics. Obtain patients pulse and blood pressure while supine. Have the patient sit up for one minute; Obtain the patient's blood pressure and pulse while sitting. If positive orthostatic changes occur while sitting, DO NOT continue to the standing position. Have patient stand for one minute. Free standing, not leaning. Obtain patients pulse and blood pressure while standing. Have someone stand on each side of the patient in case of orthostatic syncope
  19. 19. Orthostatic Blood Pressure Orthostatics are considered POSITIVE if: The patient was unable to tolerate standing and became severely symptomatic. If pulse has increased by 20 BPM OR systolic blood pressure decreased by 20 mmHg, the orthostatics are considered positive. As an alternative, an increase of 10 BPM AND a decrease of 10 mmHg may also be considered positive if symptomatic. Document the time and vital signs for supine and standing positions on/with the patient care report (PCR). KEY Points: You need both PULSE and BLOOD PRESSURE You need the patient to be in each position for a full minute. If they cant complete the test, it is considered positive.
  20. 20. Monitoring Blood Glucose Source: Accu-Chek Aviva used with permission of Roche Diagnostics. Blood glucose monitoring kit
  21. 21. Monitoring Blood Glucose Perhaps the single most important factor in a diabetics health is how well they monitor their own BG. Severity of diabetic complications depends on patients average blood glucose level.
  22. 22. Glucose Monitors Facts Personal use: Calibrated Monthly (rare) For EMS use: Calibrated WEEKLY Most have a chip which need to be changed with EVRY BOTTLE OF NEW STRIPS Affected by temp Affected by time (samples must be applied w/in 30 60 seconds)
  23. 23. Blood Glucose Monitoring Should be done daily or more often. When done by EMS, should be done in the opposite ext. as D50 was given. Venous blood usually runs about 10 mg/dl higher than capillary blood.
  24. 24. Checking the Blood Glucose Level (BG) Glucometers are commonly found on EMS units. Determines the amount of glucose in the blood, the sample usually coming from a finger stick. Glucose is measured in milligrams per deciliter (mg/dl). A normal range is 80-120 mg/dl. Hypoglycemia is a BGL 150 mg/dl. Typically not significant until greater than 250. Often not symptomatic until greater than 400 (not always true)
  25. 25. What are the numbers? Low: 8.0 mmol/L) DKA usually seen at 250-500mg/dl
  26. 26. mmol/L vs. mg/dl What is an MMOL? It is a unit of measurement commonly used in chemistry based on the molecular weight of the substance it pertains to. To convert mmol/l of glucose to mg/dl, multiply by 18. To convert mg/dl of glucose to mmol/l, divide by 18 or multiply by 0.055.
  27. 27. SPO2 Pulse oximetry is a non-invasive method allowing the monitoring of the saturation of a patient's hemoglobin. Originally invented in the 1930s, it expaded into Ors in the 1980;s, and ER,s ICUs, and EMS Units in the early 1990s. Early models were unreliable. Current technology is not only reliable, but leading into other assessment parameters , including SPCO, SPMet, and Fluid hydration status. There are still things that can Spoof common SPO2 devices.
  28. 28. SPO2 It shines infrared light across the blood flow in the capillary beds. The sensor then reads the light reflected back. The color of the light is representative of the state of the hemoglobin (hgb) that is bound up with O2. Each hemoglobin molecule can be bound (carry) by up to four oxygen molecules. The SPO2 is an expression of the percentage (%) of hemoglobin that is bound.
  29. 29. SPO2 SPO2 is always expressed as a percentage. By contrast, PAO2 (arterial pressure of oxygen) is NOT expressed as a percentage. Even though the normal PAO2 is 80-100 mmhg it can be over 400 mmhg.
  30. 30. SPO2 In Order to have a reliable reading, you must have: A good site to sample Adequate perfusion to that site Appropriate sensor A visible waveform to assess quality of reading
  31. 31. SPO2 Spoofs CO Poisoning Cyanide Poisoning Hypothermia Low perfusion states Shock Nail Polish High Light situations Poor Placement
  32. 32. KEY POINT Pulse oximetry measures solely hemoglobin saturation, not ventilation, not perfusion, not inspired FIO2, and not physiologic stress. SPO2 WORKS BEST when combined with other monitoring tools, such as the EKG and especially ETCO2
  33. 33. Hyperoxemia New discussions on the use of SPO2 to detect and prevent hyperoxemia often get it wrong. Hyperoxemia is PAO2 in excess of 100 mmHg SPO2 parameters (controversial and debatable) 94% SPO2 -> give O2 94%-99% SPO2 -> give supplemental O2 only if in distress. 99-100% SPO2-> consider withholding O2 or titrating down O2 unless in severe failure
  34. 34. SPCO CO-Oxometry is the non-invasive measurement of Carbon Monoxide (CO) in the capillary beds. It is a developmental evolution from SPO2 technology, originally designed for low flow states in neonates. The current technology most commonly in use is the RAD series from masimo.
  35. 35. The Rad Series
  36. 36. Benefits Uses Signal Extraction technology (AKA SET) This new generation can be potentially used for SPO2, SPCO2, SpHg and SPMET. SET technology was originally developed to be a low perfusion state and Motion resistant SPO2, whose technology was expanded to CO-Oxometry Early device specific research papers focused on neonates, alternative sensing locations, and anesthesia settings.
  37. 37. RAD-57 Operation: Sensor Placement SENSOR PLACEMENT IS VERY IMPORTANT When possible, use ring finger, non-dominant hand. Insert finger until the tip of finger hits the STOP Block. Sensor should not rotate or shift freely on finger. LEDs (red light) should pass through mid-nail, not cuticle. There is a top and bottom, cable should be on top (nail side). Optimal LED path
  38. 38. Carbon Monoxide: Suggested Triage Algorithm Measure SpCO 0-3% >3% No further medical evaluation of SpCO needed Loss of consciousness or neurological impairment or SpCO >25% Yes No Transport on 100% oxygen for ED evaluation. Consider transport to hospital with hyperbaric chamber SpCO >12 SpCO