August CE Angina, Acute MI, Stroke

Report
Angina, Acute MI,
& Acute Stroke
1
August 2014 CE
Condell Medical Center EMS System
Prepared by: Sharon Hopkins, RN, EMT-P, BSN
Rev 8.18.14
2
Objectives
Upon successful completion of this module,
the EMS provider will be able to:
1. Describe the pathophysiology of angina.
2. Describe the pathophysiology of the acute
myocardial infarction process.
3. Describe the atypical presentations of women,
elderly, and those with long standing diabetes.
3
Objectives cont’d
4. Describe the pathophysiology of ischemic and
hemorrhagic strokes.
5. Describe field assessment of the patient
with a possible stroke including documentation of
time of onset, blood sugar level, and Cincinnati
Stroke Scale.
6. Actively participate in review of selected Region X
SOP’s.
4
Objectives cont’d
 7. Actively participate in review of a variety of EKG
rhythms and 12 lead EKG’s.
 8. Actively participate in case scenario discussion.
 9. Actively participate in calculating and
preparing medication doses for the pediatric
patient.
 10. Review responsibilities of the preceptor role.
 11. Successfully complete the post quiz with a score
of 80% or better
5
Cardiovascular Anatomy
Cardiovascular system has 2 major components
Heart
4 chambered pump
2/3 of mass is to left of sternum
Apex just above diaphragm
Base, top of heart, lies at level of 2nd rib
Peripheral blood vessels
Transport system to deliver blood to the body and
to transport waste for removal
6
Layers of the Heart
Pericardium – protective sac around heart
Epicardium - Outer most layer
Coronary vessels lie on this epicardial layer
Myocardium
Thick middle layer of cells with electrical
properties
Endocardium - Inner most layer
Lines heart chambers; in contact with
blood flow within the chambers
7
Cardiac Damage Post MI
Each individual is unique
Damage may be only on the surface or
penetrate all layers of the heart
The greater the level/degree of damage
to the heart the more negatively affected
the heart is to work as a pump
8
Diagram
of the
Heart
9
What is Acute Coronary Syndrome (ACS)?
A list of diagnoses that affect the cardiac
system
Indicates an interruption of blood flow to
the heart
Unstable angina
Non-ST elevation MI
ST elevation MI
10
What Causes ACS To Develop?
An imbalance between supply and
demand of O2
Atherosclerotic plaque rupture in coronary
artery
Thrombosis (clot) formation in artery
Coronary spasm
Dissection of blood vessel
Increased demand of O2 in face of fixed
obstruction
11
Main Contributing Risk Factors to
Cardiac Problems
Hypertension
Hyperlipidemia
Smoking
Diabetes
Notice: all of the above are considered
modifiable risk factors – you can do
something to control them!
12
Pathophysiology of angina
Chest pain/discomfort related to a decrease
in oxygen-rich blood flow
Usually due to coronary artery disease (CAD)
Atherosclerosis
Build up of plaque over time that narrows the
internal diameter of the vessel
Arteriosclerosis
Stiffening of vessels over a period of time which
makes them less pliable
Pathophysiology of Angina
13
Plaque
formation
Angina serves
as a warning
that something
is going on
Stable Angina
14
Most common form
Pain occurs when oxygen demand is
greater than the supply during periods of
increased workload of the heart
Can usually predict activities that will
trigger an event
Usually treated with rest and medication
(i.e.: nitroglycerin)
This is a warning that the patient may
have an acute MI in the future
15
Unstable Angina
Pain that is unpredictable and can occur
at rest
May not stop with rest and/or medication
Event to be taken seriously
May be predicting an imminent acute MI
in the near future
16
Variant Angina
Occurs when vessel is in spasm
Very painful
Often occurs at night
Controlled with medication
17
Treating Angina
Treated as if the patient were
experiencing an acute MI
Patient should stop activity and rest
Question if the patient has taken their own
nitroglycerin or other medication
Often, if the pain is relieved with rest and
nitroglycerin, it is usually angina, not acute
MI
18
Pathophysiology of Acute MI Process
Significant blockage of one or more
coronary arteries
Atherosclerosis is gradual process, typically
over decades, of plaque build-up on
arterial walls
Size and area affected impacts outcome
Location, location, location!
Development of Blockage
19
20
Ischemic Cascade
Heart cells around blocked coronary artery die
These do not regenerate
Collagen scar forms
Scarring increases risks for potentially life-threatening
dysrhythmias
Weakened muscle walls vulnerable to formation of
ventricular aneurysm which could rupture at any time
Injured heart tissue conducts electrical impulses more
slowly
Allows for possible development of re-entry or feedback
loop that can generate dysrhythmia
21
Pathological Types of Acute MI
Transmural – atherosclerosis affected a major
coronary artery
MI extends through whole thickness of heart
muscle
Anterior, posterior, inferior, lateral, septal walls
ST elevation noted on EKG and Q waves develop
Subendocardial
Small area below surface of wall involved in left
ventricle, ventricular septum, or papillary muscle
ST depression noted on EKG
22
Coronary Circulation
Coronary arteries (CA)
Vessels that originate in aorta
Supply the heart with it’s blood flow
Main CA lies on surface of heart –
epicardial coronary arteries
Small penetrating arteries supply
myocardial muscle
23
Collateral Circulation
Protective mechanism to provide
alternative path for blood flow in case of
system blockage
Takes time to develop
24
Coronary Arteries
Left coronary artery
Left ventricle
Interventricular septum
Part of right ventricle
Heart’s conduction system
2 branches
Anterior descending artery (LAD)
Circumflex artery
25
Coronary Arteries cont’d
Right coronary artery
Portion right atrium, right ventricle, and
part of conduction system
2 branches
posterior descending artery
Marginal artery
26
STEMI Waveform Pattern
Evaluation of ST segment elevation
0.04 seconds after J point
>2mm for males in V2 and V3
>1.5mm females in V2 and V3
>1mm in other EKG leads
Early STEMI may just display
peaked T wave
ST elevation develops later
27
Elements
of AMI
28
Myocardium and Vessel Structure
Notice
that
coronary
arteries lie
on
epicardial
surface
29
Patient Complaints and Evaluation
Symptoms that persist beyond 15 minutes
Remember that symptoms may be vague
Always consider worse case scenario and
hope for the best
When in doubt, obtain a 12 lead EKG
Remember: a negative 12 lead EKG does
not mean the patient is NOT having an MI
We are just positive when ST elevation is
present
30
Mimics of Chest Pain
Occurrences of chest pain must be fully
evaluated
Assume the worst; hope for the best
Need to consider other differential
diagnosis putting the one that is most life
threatening at the top of the list
Remember to not be fooled by atypical
presentation of AMI
31
Differential Diagnosis
…What Could This Be???
Stable angina
Esophageal spasm
Acute pericarditis
Reflux
Aortic dissection
Gastritis
Pulmonary embolism
Cholecystitis
Pneumonia
Pancreatitis
Pneumothorax
Musculoskeletal pain
32
Non-atherosclerotic Causes AMI in
Younger Patients
Emboli from infected
cardiac valves
Congenital coronary
anomalies
Coronary occlusion
from vasculitis
Coronary trauma
Coronary artery
spasms
Cocaine use
Increased O2
requirement
Decreased O2
delivery (i.e.: anemia)
33
Typical
Patterns of
Chest Pain
May be from
surge of
catecholamines
in response to
pain and
hemodynamic
abnormalities
from cardiac
dysfunction
Atypical Presentations
34
Women, elderly, long standing diabetics
Back pain
Jaw pain
Right arm pain
Indigestion
Nausea
Fatigue/weakness
Dyspnea/ shortness of breath
No pain
Atypical Presentation in Women
35
Most frequent
complaints in
women are
shortness of
breath,
weakness,
feeling of
indigestion,
and fatigue
36
Women and Acute MI
What causes atypical presentations?
Anatomical factors
Physiological factors
Pathological factors
The above list may demonstrate the causes of
the differences between males and females in
typical versus atypical presentation of acute MI
37
Atypical Presentations of Elderly
Most likely complaints
Dyspnea
Diaphoresis
Nausea
Syncope
May have atypical presentation most
likely due to altered pain perceptions
38
Atypical Presentation of Long Standing
Diabetes
Silent ischemia considered due to
autonomic denervation of heart
Nerve damage that disrupts signals
between the brain and other body parts
Diabetics recognized at risk for
atherosclerotic plaque formation and
thrombosis contributing to acute MI
39
Diagnosing Cardiac Problems
Patient history of events
12 lead EKG analysis – changes over hours & days
Large peaked T waves, then ST elevation, then negative T
waves, then pathological Q wave development
Cardiac markers – blood work
Timing of the rise and fall of enzymes can help predict
when the acute process occurred
Troponin I levels
Specific to myocardial damage
40
Cardiac Markers
41
Have you ever wondered…
What will I see on the EKG if the patient is having
angina and not an MI?
ST elevation can occur (rarely) if perfusion is poor
or some spasm is present; it could take some time
for the ischemia to normalize
When ST elevation on EKG is from a paced
rhythm or LBBB, how do you decide when to
take the patient to the cath lab?
Most often history and how the patient looks are
deciding factors. Cardiologists would rather find
normal arteries than miss an MI. Comparison with
old EKG’s could help if they are available
42
Questions cont’d….
If the patient is having atypical angina attacks,
what is the likelihood that they will have an
acute MI?
This is very predictive with a rate of at least 30%
within 30 days
Do all persons with an MI develop a diagnostic
Q wave that shows on the EKG forever?
Diagnostic Q waves do not develop immediately
and may not if response and repair is rapid. They
depend on the thickness of the infarct and length
of time before treatment
43
Delay in Seeking Care
Atypical presentations (absence of chest
pain) increase the delay before seeking
care
TIME IS MUSCLE!!!
Delay in appropriate assessment and
intervention increases the mortality rate
44
What Therapies Are Available for
Diagnosing and Treating AMI?
Angiogram / Cardiac catherization
Insertion of long flexible tube into artery or
vein
Die injected to evaluate blood flow
through coronary arteries
Fibrinolytic therapy
Medication used to dissolve the clot
45
Therapies cont’d
Angioplasty / PTCA
Percutaneous transluminal coronary
angioplasty
Balloon tipped catheter introduced into
femoral artery
Advanced to coronary artery
Balloon expanded to press clot into wall of
artery
Stent may be left to keep lumen open
“Door-to-balloon” phrase often heard
46
Therapies cont’d
CABG / “open heart”
Coronary artery by-pass graft surgery
Small vein removed from the patient (i.e.:
leg) and attached to the aorta and then a
point beyond and by-passing the
blockage
47
Angiogram With Severe LAD Stenosis
48
Stent
Placement
in LAD
49
LBBB Pattern & Paced Rhythms in
Acute MI
Diagnosis difficult based on the EKG
The baseline ST segments and T waves shift masking or
mimicking acute MI
Assume acute MI and treat as such
Hospital assessment includes lab analysis and MD
assessment
Patients may be taken to the cath lab on presumptions
MD would rather err on side of being aggressive than to
be delayed in treatment of acute process
50
LBBB Pattern on 12 Lead EKG
51
Paced Rhythm 12 Lead EKG
52
Region X SOP – Adult ACS
Adult Routine Medical Care
Obtain 12 lead EKG and contact Medical
Control for STEMI alert if ST elevation noted
Note: contact Medical Control first if ST
elevation in II, III, aVF (inferior wall MI) prior to
administration of nitroglycerin and morphine
Patient susceptible to episode of hypotension
53
ACS SOP cont’d
Determine if patient is stable or unstable
What is the level of consciousness?
What is the blood pressure?
What are the skin parameters?
If unstable, limit medication to aspirin 324 mg
chewed, if patient can tolerate
Consider IV/IO fluid challenge in 200 ml
increments
Early contact with Medical Control important
54
ACS SOP cont’d
If patient is stable
Aspirin 324 mg chewed
If chest pain, Nitroglycerin 0.4 mg sl
Screen for MI location, B/P, Viagra-type use
previous 24-480
May repeat every 5 minutes as needed
Maximum of 3 doses
Manage pain appropriately
Morphine 2 mg IVP over 2 minutes
May repeat every 2 minutes to a maximum total
dose of 10 mg
55
Aspirin
Extremely important
One of the single most important interventions
that reduces morbidity and mortality
Prevents platelet aggregation to site of
fractured plaque
Prevents increase in degree of blockage to blood
flow
Better to have patient take an extra dose than
to totally miss any coverage with aspirin
56
Development of a Stroke
Clots,
plaques, &
hemorrhage
causing
problems
57
2 Main Types of a Stroke
Ischemic – the more common (83%)
Blockage of blood flow in a vessel
Thrombotic stroke – blockage by blood clot
development in artery supplying brain
Embolic stroke - blood clot from another area of
body travels to brain and blocks blood flow
Atrial fib most common cause
Hemorrhagic – more deadly (17% occurrence)
Tearing or rupture of a weakened vessel
Blood spills into or around the brain
58
Pathophysiology of Stroke
Ischemic (blockage) versus hemorrhagic
59
Major Risk Factors for Stroke
Atherosclerosis
High cholesterol levels
Hypertension
Diabetes
Smoking
60
Additional Risk Factors Leading to
Stroke
Obesity
Alcohol consumption
Substance abuse – particularly cocaine
Oral contraceptive use
Sickle cell disease
Atrial fibrillation rhythm
Sedentary habits promoting development of deep
vein thrombosis (DVT)
Surgery, lengthy travel, immobility due to casting
61
Ischemic Stroke Symptoms
Similar to TIA but damage can be permanent
Dependent on area & size of brain affected
Most common symptom: sudden unilateral
weakness face, arm, and/or leg
Sudden confusion, trouble speaking/understanding
Sudden visual changes
Sudden trouble walking, dizziness, loss of balance
or coordination
62
Hemorrhagic Stroke Symptoms
Rupture can be from high blood pressure or cerebral
aneurysm
Location of hemorrhage, not amount of bleeding,
influences severity of stroke
Intracerebral – bleeding within the brain
Hypertension most common cause
Blood vessel abnormalities (AVM, AVF) can cause pressure
on tissue or rupture
Subarachnoid hemorrhage
Bleeding between brain and skull
Most common complaint – severe headache!
63
Arteriovenous Malformations - AVM
Masses of arteries and veins without intervening
capillaries
Vessels dilate and often twist
Tend to be congenital & near back of brain
High pressured arterial blood flow of arteries
empty directly into thin walled veins
Stress can cause rupture of vessel
Exchange of oxygen and nutrients hampered
Normally occurs via system of capillary walls
64
Arteriovenous Fistulas - AVF
Can be congenital but more often caused by
trauma that damages an artery and a vein lying
side by side in the brain
Artery and vein join together losing the protective
separation of capillary system
AVM and AVF problems
Hemorrhage into surrounding tissues
Pressure on adjacent part of brain creating
neurological deficits
65
General Treatment AVMs and AVFs
Surgery to tie off or clip arterial vessels that feed
the abnormality
Endovascular embolization
Injection of agent to block blood flow through
abnormal connection (i.e.: special glue, coil,
balloon)
Radiosurgery
External beams of radiation to injure or clog the
abnormality – can take weeks/years and can
damage surrounding tissue
66
Hospital Diagnosing of a Stroke
Confirm the problem is an acute stroke
Eliminate other possibilities
Determine type of stroke – ischemic or
hemorrhagic
3 dimensional imaging (CT scan, MRI) and other
specialized testing processes
Determine time of onset, location and severity
of stroke
Dictates treatment approach
67
Field Assessment of Possible Stroke
Maintain high index of suspicion!!!
Not all stroke presentations are clear cut!!!
Blood glucose level to rule out other issues
Cincinnati Stroke Scale
Facial droop – right, left, none
Arm drift – right, left, none
Speech – clear, not clear
Did we mention maintain high index of
suspicion???
Hospital Treatment of Stroke
68
Goal – remove blockage and restore blood flow
 Thrombolytic drug therapy – tPA (clot-buster)
Short window of time to deliver (3-41/2 hours from
onset)
 incidence of intracranial bleeding after this time
 Mechanical device on end of catheter to pull
out all or part of clot
Requires specialized surgery and practitioner
 Administer antiplatelet meds (i.e.: aspirin)
 Maintain normal blood sugar levels
Abnormal levels can aggravate stroke damage
69
Region X SOP Treatment - Stroke
Adult Routine Medical Care
Determine time of onset of symptoms
Referred to as “last known normal”
Obtain blood glucose level
Treat if level <60
Perform Cincinnati Stroke Scale
Record specific abnormal responses in the narrative
Box provided in Image Trend only allows
normal/abnormal comment
70
Stroke SOP cont’d
Contact Medical Control
Needs early notification to prepare timely
response
If rapid neurological deterioration, ventilate pt
1 breath every 3 seconds
Document 20/minute assisted for respiratory rate
Consider Drug Assisted Intubation if needed
71
Treatment Stages for Stroke
Prevention
Behavior modification & lifestyle changes
Use of anticoagulants/blood thinners
Prevents clot formation or growth; does not
dissolve clots already formed
Intervention during acute phase
Intensive care immediately after
Rehabilitation
Physical , occupational, speech, audiology
therapies as an in or out patient basis
72
Stroke Outcomes
10% stroke survivors recover almost completely
25% recover with minor impairments
40% recover with moderate to severe
impairment
Will require special care
10% will require care in nursing home or other
long-term care facility
15% die shortly after the stroke
73
Patient Role in Stroke Care
Recognition of signs and symptoms of a stroke
Important role of the healthcare worker to
educate the public on this information
Activating 911 without delay
Minimizing risk factors by adopting healthier life
style choices
74
EMS Role in Stroke Care
Determine general impression keeping high
index of suspicion for stroke
Perform appropriate physical exam
Obtain adequate history
Transport to closest appropriate hospital with
minimal delay
Providing early report allows receiving facility to
be prepared – clock is ticking!
TIME IS BRAIN!!!
75
Obtaining Pre-hospital 12 Lead EKG’s
Many patients will be monitored for their
baseline rhythm
Not all patients monitored require a
12 lead EKG
Any 12 lead EKG obtained must be
interpreted and transmission attempted to
the receiving facility, if capable
76
12 Lead EKG’s
When in doubt, obtain a 12 lead EKG
Silent MI’s do occur
The patient has absolutely no complaints of pain
Any complaints will most likely be very vague
Absence of ST elevation (non-diagnostic EKG)
does not mean the patient has no cardiac issue
going on
Maintain high level of suspicion based on clinical
presentation and history of present illness
77
Case Scenario #1
37 y/o male crushing chest pain over the sternum
Cool/clammy, anxious
VS: B/P 90/58; P – 124; R – 26; SpO2 96%; pain 3/10
EKG monitor attached
Your general impression?
Acute MI until proven otherwise
Differential should include other cardiac problems,
respiratory problems, GI problems
ALWAYS go for the worst case scenario!!!
Case Scenario #1 – What’s this rhythm?
78
Sinus tachycardia
 What other assessments need to be obtained that
help narrow down a general impression?
12 lead EKG
Head-to-toe hands-on assessment especially of
cardiac and respiratory systems
79
Case Scenario #1
What interventions have been started?
Vital signs, pulse ox, pain scale
Preparation to obtain 12 lead EKG
Aspirin to chew if no contraindications
Hold nitroglycerin until B/P, 12 lead EKG reviewed
and history verified of no Viagra type drug use
last 24-480
ST elevation in inferior wall (leads II, III, aVF) would
prompt restriction of therapies that would trigger
vasodilation responses
80
Case Scenario #1 – Reassessment
VS: B/P 100/60; P – 106 irregular; R – 22; SpO2 97%
RA; pain 2/10; lungs remain clear
What is the rhythm?
Sinus rhythm with multifocal PVC’s
81
Case Scenario #1 - Reassessment
Do you treat the rhythm?
Monitor for now
FYI: PVC’s common dysrhythmia in COPD &
cardiac irritability; they don’t all need to be
treated
VS: B/P 106/64; P - 98 reg; R – 22; SpO2 98% RA
VS: B/P 110/70; P – 72 reg; R – 16; SpO2 100% RA;
pain 0/10
82
Case Scenario #2
55 y/o female presents with weakness in right
arm starting 1 hour ago
Appears shaky and scared; warm and dry
Hx: elevated cholesterol levels, mild
hypertension
VS: B/P 160/92; P – 88; R – 18; SpO2 99% RA
What is your general impression and what
assessments or interventions would be done?
83
Case Scenario #2
General impression to consider
Acute stroke high on the list
Could be anxiety, slept funny, resting arm in
awkward position
Can you rule out stroke based on patient age
and absence of risk factors?
NO!
Young children can have strokes
Usually different etiology than older adults
Case Scenario #2
84
Can symptoms predict part of brain affected?
Yes
Frontal lobe – planning, problem solving,
personality, higher cognitive functions
Parietal lobes – touch, pressure, fine sensation
Lt parietal – expressive/receptive aphasia
Rt parietal – visuo-spacial deficits
Hard to find way around even familiar surroundings
Temporal lobes – smells and sounds; short term
memory
Occipital lobe – processing visual information
85
Case Scenario #3
69 y/o female c/o intermittent SOB several days
Alert, tired looking, lightheaded, increased
fatigue, poor appetite, nausea
Hx: Hypertension,  cholesterol, GERD; ½ PPD
smoker x20 yrs (has quit)
VS: B/P 170/80; P – 80; R – 16; SpO2 96% RA
Lungs clear; abdomen soft, non-tender
86
Case Scenario #3
What is the rhythm strip?
Sinus rhythm with 1 PAC
Would you obtain an EKG?
You should; vague cardiac presentations
common in woman and elderly
Case Scenario #3 – EKG Interpretation?
87
Normal – no ST elevation noted (or ST depression)
88
Case Scenario #3
If an EKG is normal (i.e.: lacks ST
elevation), does this mean the patient for
sure is not having an acute MI?
No; patient should still be treated for ACS
ASA
NTG if applicable
Morphine if necessary
Case Scenario #3
89
Suddenly, the patient becomes unresponsive
Now what do you do???
Assess the patient; look at the monitor while
checking for a pulse
What’s the rhythm?
Torsades (pulseless VT)
There is no pulse – now what???
Prepare to defibrillate and begin CPR
90
Case Scenario #3
What therapies are necessary running this
code?
Defibrillation attempts every 2 minutes
Immediate return to CPR with compressions
Epinephrine 1 mg IVP/IO every 3-5 minutes
Alternate Epi with Amiodarone
300 mg IVP/IO first dose
150 mg IVP/IO repeated dose
Common Therapies to Prevent Future AMI
91
Anti-platelet therapy
Aspirin and/or Plavix
Beta-blocker
Decrease workload of heart
Meds end in “olol”
ACE-inhibitors
 development of heart failure
Meds end in “pril”
Statin therapy
To lower LDL levels of cholesterol
92
Case Scenario #4
78 y/o male presents with weakness and
dizziness; complains of inability to get out of bed
Hx: Hypertension, gout, diabetes, MI x2 with hx
CABG 3 years ago
Alert and oriented; responding to all questions
VS: B/P 172/86; P – 150 irregular; R – 20; SpO2 96%
RA; denies pain; lungs clear
What is your general impression?
93
Case Scenario #4
General impression?
Effects of feeling “under the weather”
Stroke
Silent MI
Dehydration
Natural aging process
Could be anything and nothing
94
Case Scenario #4
What’s the rhythm?
Rapid atrial fibrillation
What are the risks to this patient?
Atrial fibrillation causing a stroke from emboli in atria
95
Case Scenario #4
What are the greatest risk factors for stroke?
 Atherosclerosis
 High cholesterol levels
 Hypertension
 Diabetes
 Smoking
96
Case Scenario #4
If this were a stroke, what are the important points
of assessment & care for EMS to provide?
Assessment
Time of last known normal
Blood sugar level
Cincinnati Stroke Scale
Interventions
Rapid identification and rapid transport
Early report called to receiving facility
Monitor the rapid heart rate – no interventions for now
97
Medication Preparation for Pediatric
Patients
CE for September will be running a code for the
pediatric patient
In preparation, review math calculations for the
pediatric patient this month
Practice reading the SOP’s for orders, following
the pediatric medication charts in the SOP’s,
and comparing information with the Broselow
tape
98
Pediatric Medication Calculation
Determine the proper dosing for the following
situations
Be prepared to draw up different volumes of
pediatric doses
Compare answers listed in the SOPs with those
listed on the Broselow tape
99
Check the SOP’s and Broselow for
dosing and compare answers:
Amiodarone for 55#
Versed for 80#
Fentanyl for 60#
Glucagon for 65 #
Narcan for 90#
Valium for 35#
Epinephrine 1:10,000 for 40#
Zofran for 30#
100
Pediatric Medication Calculation
Region X SOP
 Amio 24 kg – 2.4ml/120mg
Broselow Tape
 Amio – orange – 130mg
 Midazolam – green - 10mg
 Versed 36kg – 0.72ml/3.6mg
 Fentanyl–orange–80 mcg
 Fentanyl 26kg – 0.26ml/13mcg
 Glucagon – orange - 1mg
 Glucagon 28kg – 1ml/1mg
 Naloxone –up to 36 kg
 Narcan 40kg – 2ml/2mg
 Diazepam – white - 3.3mg
 Valium 16kg – 0.64ml/3.2mg
 Epi1:10,000-white Epi 1:10,000 18kg – 1.8ml/0.18mg
1.7ml/0.17mg
 Zofran 12 kg – 0.6ml/1.2mg
 Zofran-yellow-not listed
101
Pediatric Medication Calculation
Why the difference in dosing from the Region X
SOP’s and Broselow tape?
Each group may use a different formula for the
medication
Often medication dosing is provided in ranges
Example: 1 – 3 mg/kg
Reminder: Region X SOP – go to the next
lowest/closest weight listed in charts
Can always give more if needed
102
Region X SOP Resource vs Broselow
Tape
Region X SOP provides “ml” for filling the syringe
AND “mg” for documentation
Broselow tape often provides only “mg”
Still need to calculate the “ml” to fill the syringe
Region X SOP medication charts list trade and
generic names
Broselow tape often uses only 1 medication
name (i.e.: Diazepam, Naloxone, Midazolam,
crystalloid fluids
103
Preceptor Role
Provides a guide to transition and integration
into the workforce
Supports development of clinical competence
and confidence for growth of a professional
healthcare provider
Sharing skills and knowledge assures the
development of others to continue to provide
superior care in an increasingly complex care
environment
Must be supported by all in the workplace
104
Bibliography
 Bledsoe, B., Porter, R., Cherry, R. Paramedic Care
Principles & Practices, 4th edition. Brady. 2013.
 Mistovich, J., Karren, K. Prehospital Emergency Care 9th
Edition. Brady. 2010.
 Region X SOP’s; IDPH Approved April 10, 2014.
 http://www.merckmanuals.com/professional/neurologic
_disorders/spinal_cord_disorders/overview_of_spinal_cor
d_disorders.html
 http://lifeinthefastlane.com/ecg-library/basics/leftbundle-branch-block/
 http://www.interactive-biology.com/75/show-me-adiagram-of-the-human-heart-here-are-a-bunch/
105
Bibliography cont’d
 https://sites.google.com/site/caduceusnewsletter/medi
cal-reference/myocardial-infarction---by-cornelia-riedl
 http://www.clevelandclinicmeded.com/medicalpubs/di
seasemanagement/cardiology/complications-of-acutemyocardial-infarction/
 http://www.uhnj.org/stroke/types.htm
 http://floatnursemike.blogspot.com/2012_10_01_archive.html

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