Altered Mental StatusAging Process

ECRN CE MOD I 2015

CONDELL MEDICAL CENTER

EMS SYSTEM

SITE CODE: 107200E-1215

Prepared by: Sharon Hopkins, RN, BSN1

Objectives

Upon successful completion of this module, the ECRN will be able to:

1. Be able to distinguish presence of neurological problems given a

variety of signs and symptoms.

2. Predict which patients may be presenting with a stroke based on

chief complaint and signs and symptoms.

3. Prioritize transport for patients presenting with a variety of

neurological emergencies.

4. Discuss the normal aging process.2

Objectives cont’d

5. Determine physical and psychological clues that would suggest

elder abuse or neglect.

6. Discriminate a field neurological assessment from an in-hospital

assessment.

7. Review selected Region X SOP’s as related to the topic

presented.

8. Review case scenarios presented.

9. Know how to assess for successful insertion of an IO needle.

10. Review responsibilities of the preceptor role.

11. Successfully complete the post quiz with a score of 80% or

better.3

The Nervous System

• Body’s principle control system

• Regulation primarily through electrical impulses transmitted thru nerves

• 2 main divisions

• Central nervous system – brain and spinal cord

• Peripheral nervous system (PNS) – with 2 major subdivisions

• Somatic NS – voluntary functions

• Autonomic NS – involuntary functions – 2 divisions

•Sympathetic (SNS) and parasympathetic nervous systems (PNS)4

Central & Peripheral Nervous System

5

Defining Neurological Problems –Central Nervous System (CNS) Disorders

• Key sign is an altered level of consciousness

• Loss of ability to respond to stimuli and awareness of environment

• Two mechanisms produce mental status changes

Structural lesions

• Destruction or encroachment on substance of brain (i.e.: tumor, trauma/bleeding, degenerative diseases, parasites)

Toxic-metabolic states

• Presence of circulating toxins or metabolites or absence of necessary metabolites (i.e.: oxygen, glucose, thiamine (Vit B1)) 6

Peripheral Nerve Insults

• Malfunction or damage of peripheral nerves results in peripheral neuropathy

• Single or multiple nerves can be affected

• Single nerves usually from local conditions (i.e.: trauma, infection, compression (i.e.: carpal tunnel))

• Multiple nerve damage characterized by demyelination or degeneration of peripheral nerves

• Myelin is protective sheath surrounding nerves

• Destruction of myelin leads to sensory, motor or mixed deficits (i.e.: diabetic neuropathy, Guillain-Barre syndrome)

7

Myelin Sheathing

8

Central Nervous System - CNS

• Common causes of CNS disorders

Drugs

• Depressants, hallucinogens, narcotics

Cardiovascular insults

• Arrest, stroke, shock, dysrhythmias, hypertensive encephalopathy

Respiratory insults

• COPD, toxic gas, hypoxia

Infections

• AIDS, encephalitis, meningitis, parasites9

Examples Neurological Disease/Problems

• ALS – Lou Gehrig’s Disease

• Alzheimer’s disease

• Bell’s palsy

• Guillain Barre syndrome

• Huntington’s disease

• Multiple sclerosis

• Muscular dystrophy

• Parkinson’s disease

• Polio

• Seizures

• Spina Bifida

• Stroke

• Tumor

• Trigeminal neuralgia

10

General Impression

• NOT the role of EMS to diagnose the specific neurological disease present

• Important to note that SOMETHING neurological is happening!

• Obtain adequate history – pertinent past and present

• Perform detailed assessment and reassessment

• Includes neurological assessment

• Monitoring the trending

•Knowing what to do with the trend – action & reporting to MC

11

General Impression cont’d

• General impression is formed when first meeting the patient

• General impression revised as more information is gathered

• General impression guides the responder in choice of intervention

• Information obtained from a variety of sources

• Scene size up – viewing the scene is an advantage EMS has over ED

• Evaluation of surroundings

• Evidence of toxic exposure or trauma

• Clues to the patient’s condition12

Clues to Patient Conditions

General Appearance…

Speech…

Skin…

Posture/gait…

13

Clues - General Appearance

Determine patient’s normal or baseline

• Is patient conscious?

• If not, do they respond to voice (3*), pain (2*) or not at all (1*)?

• Is patient alert?

• To what degree?

• Is patient confused?

• Pleasantly confused or using inappropriate words?

• Can the patient sit upright?

* - reflects GCS score

14

Clues - Patient Speech

Determine patient’s normal or baseline

• Can the patient speak?

• Is the speech clear and coherent with appropriate content to the situation?

• Does the patient speak in full sentences?

• Remember to document if unable to speak in full sentences (i.e.: “2-3 word sentences”) especially when related to complaints of difficulty breathing

• Is the speech slurred? 15

Clues - Patient's Skin

Determine patient’s normal or baseline

• What is the color – pink, pale, cyanotic?

• What is the temperature - warm, hot, cool?

• Is the patient dry, diaphoretic or clammy?

• Is facial drooping present?

• If yes, to which side?

16

Clues - Patient’s Posture/Gait

Determine patient’s normal or baseline

• Is the patient able to maintain an upright position?

• If the patient is leaning, to which side?

• If you observe the patient walking, do they have a steady gait or do they stagger?

17

AVPU and GCS

• AVPU determines mental status

A – alert and aware of surroundings

V – responds to verbal stimuli

P – responds to painful or tactile stimuli

U – unresponsive

• Glasgow Coma Scale – GCS

Used to monitor a patient’s condition

Used as a predictor of morbidity and mortality

18

Assessing Cerebral Function Via Emotional Status

• Look for changes from normal or baseline

• Mood –affect natural or irritable, anxious, apathetic, depressed, manic, happy?

• Thought – logical, appropriate, scattered?

• Perception –appropriate interactions and perception of environment?

• Judgment – logical, using reasonable and sound judgment?

• Memory and attention –short and long term memory intact? Able to pay attention and maintain conversations?

19

Patient Assessment & Monitoring

• Need to know patient’s baseline to best make sense of any changes noted

• Changes from “normal” must be investigated

• Respiratory center is in the brain

• Must carefully monitor respiratory patterns if evident problem in central nervous system (CNS)

• Remember focus of primary assessment

• Determine any life threatening condition and address it20

Nervous System Evaluation

• Evaluation of sensoriomotor status, motor system status, and cranial nerves

• Sensoriomotor status - assessment of sensation and motor function

•Can you feel this? Can you move that?

• Motor system status

• Assessment of tone, strength, flexion/extension, coordination, balance

•Many motor functions not tested by EMS in the field

• Cranial nerves

• 12 pairs extend from lower surface of brain21

12 Pairs Cranial Nerves

• Originate from base of brain

• Provide sensory and motor innervation mostly to head and face

• Each pair can carry sensory, motor, or both types of fibers

• Limited assessment of cranial nerves performed in the field

• Usually assessment limited to CN III – pupillary response

22

Mapping the 12 Cranial Nerves

23

Acute Stroke – A Neurological Insult

• Injury or death of brain tissue

• Usually due to interruption of cerebral blood flow

• Oxygen deprivation causes damage to affected tissue

• 2 categories – occlusive and hemorrhagic

• Early recognition and rapid transport can improve patient outcome

• High risk history – atherosclerosis, heart disease, hypertension24

Acute Occlusive Stroke

• 85% of incidence of strokes

• Caused by blockage of cerebral artery with clot or foreign matter

• Embolic stroke from material that travels from a remote site

• Thrombotic stroke is buildup on plague in vessel that blocks flow of blood

• Ischemia due to inadequate blood supply leads to infarction with death of tissue

• As tissue dies, it swells causing further damage

25

Acute Hemorrhagic Stroke

• 15% of incidence of strokes

• Caused by rupture of a vessel

• Bleeds within the brain – intracerebral

• Can bleed in space around outer surface of brain – subarachnoid

• Often from congenital blood vessel abnormality

•Weakened vessels (aneurysms) or collection of abnormal blood vessels (AV malformations)

• Common in hypertensive patient especially when poorly controlled26

Thrombotic/Embolic Stroke vs Hemorrhage

27

Heightened Suspicion of Stroke

• Facial drooping

• Arm drift

• Unilateral weakness (hemiparesis)

• Unilateral paralysis (hemiplegia)

• Dysphasia (difficulty speaking)

• Aphasia ( inability to speak)

• Confusion and agitation

• Headache

• Dizziness

• Visual disturbances

• Unilateral numbness or tingling (paresthesia)

• Inability to recognize by touch

• Gait disturbances

• Incontinence

• Coma 28

High Index of Suspicion

• NOT everyone presents with one of the classic 3 signs of stroke

Facial droop

Arm drift

Speech not clear

• Pay attention to the odd complaints

• I can’t get out of bed – determine “why”

• My legs don’t seem to work – determine “why”

• Something is “just not right” – consider if it is cardiac or neurological

• I have a headache / dizziness – especially when these cannot be explained

29

Predisposing Factors Contributing to Stroke

• Hypertension – especially poorly controlled

• Diabetes

• Abnormal lipid levels – high cholesterol

• Oral contraceptive use

• Sickle cell disease

• Cardiac arrhythmia – notably atrial fibrillation30

Transport of Patients With Acute Stroke

• Transport expedited to closest appropriate hospital

• All hospitals in Lake County are designated Primary Stroke Centers

• Have internal process to assemble their “stroke team” for patient care

• Prepared to quickly obtain a CAT scan

• Used to rule out hemorrhagic bleed

• EMS to minimize scene time

• If there is a delay in transport, make sure it is time well spent

• IV’s attempted only if process will not delay transport 31

Minimum Field Assessment All Potential Strokes

• Establishing last known normal time

• This is not necessarily the time patient was found!

• Cincinnati Stroke Scale

• Obtaining capillary blood glucose level

• Perform a finger stick versus obtaining from an IV site

• Complete a baseline field neurological assessment

• GCS

• Pupils

• Sensory and motor response

32

Field Neurological Assessment

• Establish level of consciousness – AVPU scale

• Compare to patient’s normal baseline if possible

• Obtain GCS – watching for trends

• Always give highest score possible

• Vital signs – watching for trends

• Head insult -B/P; pulse rate; irregular respirations

• These changes known collectively as Cushing’s Triad

• Shock -B/P; pulse rate33

Field Neuro cont’d

• Pupillary reflex – 3rd cranial nerve

• Abnormal pupillary response points to same side of head injury/insult

• Sensory and motor

• What can patient feel? What can patient move?

• Abnormal motor and sensory response reflects opposite side of head injury/insult

• Blood glucose level

• Obtained on all patients with altered level of consciousness and potential stroke 34

What About These Pupils???

Could be normal or point to injury left side of brain

• Could indicate exposure to narcotics or response to light

• Could indicate exposure to stimulants or response in darkened room

• Cataracts 35

The Aging Process – Not For Sissies

36

The Aging Process

• Survival rates are up; life expectancy increasing

• Birth rates are down

• Healthcare providers need to be prepared for an increase in numbers of the aging population

• EMS calls are very stressful on the elderly

• Elderly often equate illness with death

• Often don’t report changes in health – viewed/considered as normal process of aging

37

Understanding Problems of the Aged

• Poverty and loneliness prevalent

• Social support system declines especially if living alone

• Disease and disability often linked to unhealthy and unsafe behaviors

• Independence is important concept

• Functional impairment affects self sufficiency

• Tight finances and limited mobility become issues

Decrease in adequacy of nutrition

Safety issues

Under adherence of medication (reduce doses to save money)38

On Aging

• Aged susceptible to same disease as the young but maintenance, defenses, repair processes are weaker

• Progressive loss of function with aging body

• Increases likelihood of malfunction

• Vital organs lose ability to compensate in times of need

• Aged often have more than 1 disease/illness present

• Average of 6 medical disorders co-exist in elderly

• Disease in 1 organ often leads to deterioration in another system

• Presence of co-morbidities/other disease causes vague complaints or non-specific complaints not linked to any one disorder

39

Think About This…

• Being “old” does not automatically mean you have dementia

• Having dementia doesn’t mean you are old

• “Loosing your keys” doesn’t mean you have Alzheimer’s

• Not knowing what keys are or what to do with them may indicate Alzheimer’s

• 5.2 million Americans have Alzheimer’s

•200,000 are under 65 years of age

• 6th leading cause of death in the USA

• Women 3:1 over men 40

Road Blocks to Medication Compliance

• Limited income

• Memory loss

• Limited mobility

• Sensory impairment (hearing, sight, understanding directions)

• Multiple or complicated drug therapies

• Fear of toxicity

• Childproof containers (especially with arthritis)

• Duration of drug therapy (longer the therapy, the less compliance) 41

Tactics to Increase Medication Compliance

• Improving patient-physician communication

• Acknowledging/accepting that a disease or illness is serious

• Drug calendars or reminder cards

• Compliance counseling

• Easy to open packaging

• Multiple compartment pillboxes

• Transportation services to pharmacy

• Clear, simple directions written in large type

• Ability to read42

Problems Related to Lack of Mobility in the Elderly

• Poor nutrition

• Difficulty with elimination

• Poor skin integrity

• Greater predisposition for falls

• Loss if independence and or confidence

• Depression from “feeling old”

• Isolation and lack of social networks 43

Contributory Factors to Communication Difficulties

• Sensory changes related to aging

• Impaired vision or blindness

• Impaired or loss of hearing

• Altered sense of taste or smell

• Lower sensitivity to pain and touch

44

Impaired Vision

Color blindness –

what number do you see?

Nearsightedness

Macular degeneration

45

Common Complaints of the Elderly

• Fatigue and weakness

• Dizziness – vertigo – near-syncope

• Falls

• Headache

• Insomnia

• Dysphagia – difficulty swallowing

• Loss of appetite

• Inability to void – constipation - diarrhea46

Impact On Forming General Impression

• Living situation

• Level of acuity

• Network of social support

• Level of independence

• Medical history

• Sleep patterns

• Elderly often vague; consider their complaints as trivial

• Often complain of 1 thing which is not the main problem

• Healthcare worker often has to “dig” to find the real story 47

Patient Assessment in the Elderly

• Obstacles

• “Normal vitals” are not normal in the elderly

• Pneumonia for example

• Fever often absent

• Chest pain and cough less pronounced

• Etiology (cause) often due to aspiration versus infection48

Mechanism of Injury - Falls

• Fall related injuries leading cause of accidental death in elderly

• Always ask/determine “why” a patient fell

• Intrinsic falls – related to the patient

• History of falls, dizziness, weakness, impaired vision, altered gait, CNS problems, decrease mental alertness, certain medications

• Extrinsic falls – related to the environment

• Slippery floors, no handrails, loose throw rugs 49

Spinal Injuries In The Elderly

• Degenerative changes occur in the spine as a person ages

• Increases risk of spinal fractures with even minor forces

• Odontoid fracture (C2) especially common in elderly

• Mechanism of injury in elderly are low impact falls especially falling and striking chin - look for abrasions!

• Mechanism in younger aged population are high impact MVC

• Neck pain is common without spinal cord injury

• Treatment can range from surgery to immobilization in halo vest or collar 50

Halo brace

Assessment of Potential Spinal Injuries

• Neck palpated feeling for pain or step off

• Strength tested in all extremities

• Sensation tested in all extremities

• Ability to shrug shoulders tested

• Results documented; reassessments continued

• Presence of injury assumed until x-ray confirmation obtained

• Based on mechanism of injury (MOI), elderly deserve spinal motion restriction/immobilization until proven otherwise

• Remember – minimum MOI can relate to significant injury in elderly 51

Backboard Use In Elderly

• Consider anatomical positioning of the patient

• Kyphosis (abnormal curvature of spine; hump) often present

• Patient will need extra padding to fill in the gaps

• Laying on a backboard can increase the risk of skin breakdown

52

Ethical Considerations When Caring For the Elderly

• May question the patient’s capacity to live on own

• May question decisional capacity to give consent

• Faced with Advanced Directives

• Trying to honor the patient’s wishes

• Hesitant caregivers should raise suspicion of abuse

• Remember - increased rate of depression and suicide noted in elderly

53

Resources of Community Support

• Catholic Charities – 1-847-782-4000 (M-F - 0830-1630)

• Private, not-for-profit social service agency

• Can evaluate the living conditions

• Service Directory available online www.catholiccharities.net

• United Way Human Services Resource Guide

• Guide book to provide information about a broad range of available services – should be available in all ED’s

• The old “red book” of resources

• Guide book available online www.LIVEUNITEDlakecounty.org.

• Online searchable database at www.FindHelpLakeCounty.org54

Human Services Resource

Guide

Put together by United Way of Lake County

55

Preserving The Health Status of the Elderly

• Disease/illness

• Encourage routine screenings

• Keep up to date with immunizations

• Tetanus booster, annual flu

• Consider one time pneumococcal (for pneumonia) and shingles vaccine

• Pharmacological

• Regularly review all medications including over the counter (OTC)

• Focus on potential interactions and side effects

• Average elderly person takes 4.5 medications per day 56

Health Status cont’d

• Dental care

• Encourage regular checkups and dental hygiene

• Important for nutrition and well-being

• Mental/emotional health

• Observe for depression, disrupted sleep patterns, psychosocial stress

• Check effectiveness of support networks57

Protecting Our Elders

• Elder abuse

• Any physical injury, sexual abuse or mental injury inflicted on a person age 60 or older other than by accidental means

• Elder neglect

• A failure to provide adequate medical or personal care or maintenance, which failure results in physical or mental injury to a person or in the deterioration of a person’s physical or mental condition

58

Elder Abuse and Neglect

• Primary presentation – unexplained trauma

• Average abused patient over 80 years old

• Patient usually has multiple medical problems

• Senile dementia often present

59

Profile Elder Abuser

• May be a family member or healthcare worker in nursing home and other health care facilities

• No socioeconomic descriptions

• Usually older person no longer totally independent

• Abuser experiencing extra stress

• Typical to be sleep deprived, experiencing marital discord, financial problems, and work-related problems

60

Signs of Physical Elder Abuse

• Bruises

• Described by color which indicates age of the injury; do not use words “new” or “old” to describe

• Broken bones

• Burns, abrasions

• Pressure marks

• Odd explanations of the injury (“she ran into a wall”) 61

Signs of Elder Neglect

• Dirty clothes

• Soiled diapers

• Bedsores

• Unusual weight loss

• Unusually messy home –

• Especially if a change from previous conditions

• Medical aids not readily available

• Eye glasses, hearing aids, cane, walker62

Signs of Verbal or Emotional Abuse

• Withdrawn, apathetic

• Unusual behavior such as rocking, hitting

• Nervous, fearful behavior, especially around caregiver

• Strained or tense relationship between caregiver and elder

• Caregiver snapping or yelling at the elder

• Forced isolation by family member or caregiver

63

Signs of Sexual Abuse in Elderly

• Bruises around breasts and/or genital areas

• Evidence of venereal disease

• Vaginal or rectal bleeding

• Difficulty walking or standing

• Depressed or withdrawn behavior

• Flirtation or touchiness by caregiver

64

Signs of Financial Abuse in Elderly

• Unpaid bills

• Money disappearing and unaccounted for

• Caregiver taking money for purchase that doesn’t arrive

• Unusual purchases person wouldn’t normally make

• Increased use of credit cards

• More frequent withdrawals of cash

• Adding someone new to bank accounts or credit cards 65

Mandatory Reporting

• Healthcare worker including EMS personnel are mandatory reporters of suspected elder abuse or neglect

• Abuse Hot Line 866-800-1409; 24/7

• Accurately, objectively, and completely document any physical findings on the patient care run report

• EMS to relay findings to the ED staff

• ED staff also mandatory reporters

• EMS and ED to document who was notified – both groups must report their suspicions

66

Case Scenario Reviews

• Review the following case studies

• Determine your general impression after analyzing data obtained

• Interpret the results provided of the assessment

• Determine the appropriate field interventions for EMS based on Region X SOP’s

67

Case Scenario #1

• 91 y/o F found at 10am by “son” with mumbling speech

• History: hypertension, lung cancer, on hospice

• Also found to have right sided weakness

• Eyes open; does not seem to track movement in room

•What is your general impression at this point???

• Hopefully, stroke is a consideration68

Case Scenario #1

• VS: 184/98; P – 88 irregular; R – 18; SpO2 96%

• Blood glucose 157

• Eyes open; mumbling

• R side does not move, L arm randomly swatting at the air

69

Rhythm: Atrial fibrillation

Risk to patient with this? Acute stroke

What is the rhythm???

Case Scenario #1

• Impression???

• Acute stroke

• EMS assessment (the minimum related to “stroke”)

• Cincinnati Stroke Scale

• Blood glucose

• Report to receiving hospital

• Expedited transport

70

Case Scenario #1 – Points to Emphasize

• Clarify last known normal versus when found

• Important distinction to determine if patient is in window of opportunity for intervention with fibrinolytic (TPA)

• Verify who the bystanders are – don’t assume relationships

• The “son” was actually the nephew (who did have power of attorney)

• Cincinnati Stroke Scale

• EMS to report if the components were normal or abnormal

• If results abnormal, the ECRN should inquire which ones specifically

• Reassessment/trending less valuable without accurate data 71

Case Scenario #1 – Follow-up

• Code Neuro was activated by pre-hospital report

• CT scan obtained was “negative”

• Indicates no active bleed; evidence of acute stroke takes time to develop (hours to days if at all – depending on size and location) to see effects on CT repeated later

• Need bedside assessment to determine if symptoms related to acute stroke and then decide on intervention

• Supportive care provided to this patient

• Due to failing health and extensive status of cancer, family elected no aggressive intervention

72

Case Scenario #2

• 46 y/o M was noted to be stumbling around a public area; using halting speech

• EMS was summoned by a concerned by-stander

• VS: 130/70; P – 138; R – 26; SpO2 96%

• What do you think is going on???

• Could be lots of issues (think AEIOU – TIPS as a starting point)

• By the way, patient history includes ALS73

Case Scenario #2

• What is ALS (Lou Gehrig’s Disease)?

• A progressive, degenerative neurological disease causing rapid decline of voluntary muscles

• Weakness, loss of motor control, difficulty speaking, cramping

• Eventual weakness of diaphragm leads to respiratory insufficiency

• Patients must be on ventilators at this stage

• Poor prognosis – most die within 3-5 years of diagnosis

• Cause of death usually a pulmonary infection 74

Case Scenario #2 - Assessment

• Eyes open

• Patient oriented and conversant, just halting speech pattern

• Extremities all move to command but in jerky manner

• GCS?

• 4, 5, 6 for total of 15

75

Sinus tachycardiaWhat’s the rhythm?

Case Scenario #2

• So, why is EMS at the scene? – Concerned by-stander

• Eventually discover patient is short of breath and that is new

• RR was 26 and SpO2 was 96%

• Would O2 be indicated?

• Yes, due to respiratory complaint (even though SpO2 >94%)

• Remember: ALS is a disease that eventually affects the respiratory system and causes respiratory malfunction (weakens the diaphragm)

76

Case Scenario #2

• What was rhythm interpretation?

• Sinus tachycardia

• Would you give Adenosine?

• NO!!!

• Sinus tachycardia NOT treated with medication!

• Find the causes of sinus tachycardia and treat the causes

• EMS to present rhythm strip to ED staff to place on the patient's hospital medical record (and 12 lead EKG’s, too)

77

Case Scenario #3

• 51 y/o F with sudden onset headache, dizziness, nausea

• Witnessed by husband who then called 911

• Found sitting in chair leaning to the right side

• Mental status deteriorated from time of initial call

• Eyes open but not tracking movement

• Non-verbal

• Right arm hanging limp by side

• Does not follow command 78

Case Scenario #3

• VS: 190/110; P – 66; R – 18; SpO2 97%

• GCS – How would you score the motor response?

• Need to see the response as you apply stimuli

• When stimuli applied, patient uses left hand to grab at you

• Is it purposeful? (yes)

• Is it withdrawal?

• General impression?

• Acute stroke vs subarachnoid bleed 79

Case Scenario #3 - Interventions

• Monitor vital signs

• Trend to watch for?

• Cushing’s reflex -B/P; pulse; irregular respirations

• Closely monitor respirations

• During transport, respiratory rate drops and respirations shallow

• What is the rate to support ventilations via BVM?

• 1 breath every 5 – 6 seconds (10-12 breaths per minute)

• What is the rate for bagging via advanced airway (ETT or King)?

• 1 breath every 6 – 8 seconds (8 – 10 breaths per minute)80

Case Scenario #3 – Drug Assisted Intubation

• What medications are used if intubation performed in the field?

• Lidocaine – in presence of head insult (trauma, stroke), decreases cough reflex to minimize increase in ICP

• 1.5 mg/kg IVP/IO one time

• No precautions if bradycardia in this setting

• Etomidate – as hypnotic to induce anesthesia

• 0.3 mg/kg IVP/IO (max 20 mg - 150# on upward get 20 mg)

• Versed – benzodiazepine for post intubation sedation

• 2 mg IVP/IO every 2 minutes to desired effect; max 20 mg

• Apply cervical collar to help maintain ETT position81

Case Scenario #3 – Case Follow-up

• Pt had been diagnosed with hypertension and prescribed multiple medications several years ago – non-compliant

• Pt had subarachnoid hemorrhage due to ruptured vessel

• Taken to OR to evacuate hematoma and reduce pressure on brain tissue

• Pt remained comatose, ventilator dependent

• Received trach, PEG tube for feedings

• Poor prognosis – likely to remain in vegetative state

• Discharged to nursing home 82

Case Scenario #4

• 65 y/o M living in poor conditions

• History severe dementia (Alzheimer’s) now with worsening mental decline

• Care giver is daughter – does not live with patient

• Patient in dirty PJ’s

• Moldy food found around apartment

• Feces on floor; strong smell of urine

• Multiple bruises noted in various stages of healing

• Blue/purple – green/yellow - brown83

Stages of bruising

Case Scenario #4

• General impression?

• Unable to care for self

• Elder neglect

• Intervention – transport

• Resources

• Human Services Resource Guide by United Way of Lake County

• Catholic Charities – 847-782-4000 (M – F)

• Hospital Social Worker

• Reminder – Document color of bruises; do not use words “new” or “old”

84

IO Needle Insertion Skill

• IO needles can be placed in the field

• IO needles can be placed in the ED

• The following slides are a review of the placement and removal process

85

Intraosseous (IO) Needle Insertion EMS Guidelines

• Indications

Shock, arrest, or impending arrest

Unconscious/unresponsive or conscious patient without IV access

2 unsuccessful IV attempts or 90 seconds duration or no visible sites

• Contraindications

Extremity with acute fracture

Infection at insertion site

Previous orthopedic procedure at site (i.e.: knee replacement)

Pre-existing medical condition (i.e.: tumor, peripheral vascular disease)

Inability to locate landmarks86

IO Equipment

• EZ IO needle – 15mm 15G; 25mm 15G; 45mm 15G

• Syringe with 0.9 NS (10ml adult >88 pounds; 5ml <88 pounds)

• Primed EZ-connect tubing

• Driver

• Material to cleanse site

• Primed IV bag

• Pressure bag

87

Primary IO Landmarks – Proximal Medial Tibia

• Leg must be straight to identify landmarks

• Palpate lower edge of patella

• Identify site 2 finger widths below patella (tibial tuberosity)

• Identify site 1 finger width medially from tibial tuberosity toward big toe

88

Adult Back-up IO Landmark –Proximal Humerus (Greater Tubercle)

• Position flexed elbow tucked back & adducted; hand over navel

• Palpate prominence of greater tubercle (use heel of hand to gently strike area feeling for prominent bone) OR

• Palpate up humerus until groove of surgical neck is palpated; then move up 1 cm (1 finger width) to most prominent spot

• Site is ANTERIOR to midline89

Demonstration IO Insertion(Computer must have internet access)

• Click here to view video – humeral insertion site for IO

• Click here to view video – humeral insertion site for IO

90

What’s With the Black Lines?

• Make best determination for needle size

• Short pink 15mm – for the very young; bone palpable just under skin

• Medium blue 25mm – for the majority of patients and in proximal tibial site

• Long yellow 45mm – for the obese in proximal tibial site and for all humeral sites in the adult

• Insert needle into site until it stops – contact made with bone

• Look to verify at least one black line is visible; then begin to drill

• Verifies enough needle left to insert into site

91

Confirming IO Placement

• Feel “pop” upon insertion

• Needle stands up on own

• Able to aspirate blood or bone marrow

• May or may not be able to aspirate blood or bone marrow

• First attempt to aspirate should be prior to flushing

• Aspiration can be done at any time during infusion process

• Needle flushes easily without evidence of infiltration

• IV fluid flows once pressure bag placed around IV 92

Controlling Pain Due to Fluid Infusion

• Insertion of IO needle not that uncomfortable

• Infusion of fluids is what could cause discomfort (non-expandable space)

• Watch for pain response from patient

• Verbal complaints, agitation, attempting to grab at IO needle (purposeful movement), pulling affected extremity away (withdrawal)

• Administer Lidocaine 50 / 60 / 60

• Adult 50 mg over 60 seconds, wait 60 seconds then start infusion

• For pediatric patient administer 1mg/kg over 60 seconds, wait 60 seconds

• Slower instillation and waiting the time allows the medication to stay in the area and to work

• Your dentist doesn’t inject and then start to drill right away!!!

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IO Documentation

• Document site used

• Document size needle used

• Printed on cap of needle holder

• Remember to place wrist band on patient

• Preferably same side as insertion site

• Patients to be banded for all attempts, failed and successful94

Removing an IO needle

• Secure alternate IV access

• Stop IV infusion

• Remove IV tubing and extension tubing

• Screw any size syringe into the IO needle

• Syringe being used as a grip

• Continue to turn the syringe clockwise as you exert a pull on the needle

• Removal takes time – this is not as quick as insertion

• Once the needle is removed, dispose in a sharps container

• Cleanse the skin and apply a band-aid

• At most you may see a few drops of blood at the site95

What is a Preceptor???

• A skilled practioner that will guide and teach those less skilled

Instructor / teacher

Tutor

Counsel

• Supports the growth and development of others

• Works with a novice to help them grow toward the expert level

• Provides direction aimed at specific performances

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Art of Precepting

• Not everyone will fall into the official role of “preceptor”

• But everyone can behave as a preceptor

• Positive attitude, sound knowledge of theory and skills, desire to learn and desire to teach and guide others

• An effective preceptor can provide appropriate and effective critiques

• Timely – i.e.: immediately

• Respectful – not in punitive manner

• Pointing out what was good and what are opportunities for improvement

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ECRN Reminders

Listen attentively to the report

• If information is missing, ask for it

• Does it sound like an acute cardiac event or acute stroke???

Clarify if 12 lead EKG was transmitted

• Look for the 12 lead and hand to the ED MD

Does the call indicate need for orders outside of the SOP’s???

• As a licensed RN, need to consult with the ED MD to obtain orders not stated in the SOP’s

Is there a learning opportunity here with EMS???

• Pull them aside and use the event as a teaching opportunity; not punitive98

Bibliography

Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th edition. Brady. 2013.

Campbell, J., International Trauma Life Support for Emergency Care Providers. 7th Edition. Pearson. 2012.

Region X SOP’s; IDPH Approved January 6, 2012.

• Mistovich, J., Karren, K. Prehospital Emergency Care 9th Edition. Brady. 2010.

• http://www.helpguide.org/articles/abuse/elder-abuse-and-neglect.htm#reporting

• http://www.eldercare.gov/Eldercare.NET/Public/Index.aspx99

Bibliography cont’d

• www.FindHelpLakeCounty.org

• http://www.alz.org/alzheimers_disease_facts_and_figures.asp#prevalence

• http://www.cdc.gov/Features/ElderAbuse/

• http://www.aoa.gov (Public Services of US Administration on Aging)

• http://www.jems.com/article/intraosseus/using-humerus-bone-io-access

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