Week 7

Week 7
Reflection:
Using the Gibb's Reflective Model, i will be reflecting on the practical session we had on the 14th of March, 2016.

Description: This week we practiced some scenarios. My scenario was a 28 year old female c/o difficulty of breathing. She said this started in the morning and walking made it worse. She described it as “severe and getting worse’. The patient was talking to me so she was responsive and her airway and breathing were intact. Her skin was pink, warm, and dry. Her VS were: SpO₂ : 96%, BP: 110/75, RR: 14, HR: 108bpm. At this point I supplied the patient with 4L/min of supplemental oxygen via a simple face mask. Then I went on to gather the patient’s history. She had no allergies and took antacids and a puffer as medications. She had a history of asthma and has had several similar attacks as the presenting one. Also, she smokes 2 packs of cigarettes/ day. I gave the patient 2 of the 2.5mg/1mL nebules of Ventolin, making a 5mg/2mL of Ventolin, as an initial dose. With the Ventolin I added 2mL of NS. I then removed the simple face mask off the patient’s face and placed the nebulizer mask. I changed the flow rate to 8L/min. The patient did not feel better after this. I then proceeded and gave her 500mcg/2mL of Atrovent, also with 2 mL of NS. The patient felt a little better, but still had difficulty breathing. Therefore, I decided to administer a corticosteroid, SoluCortef, via IM. I administered 0.5 mL through the deltoid muscle. However, when I came to aspirate I asked if any blood came out, thinking that was the indication I was in the muscle. To this my teacher asked me why I wanted to know, and corrected me. Following this, I initiated rapid transport of the patient to a hospital. The patient started to feel even better, nonetheless, she still felt extreme difficulty in breathing. 

Feelings: At first I was confident in my approach of the patient. Moreover, I was certain with my diagnosis and most of my management of the patient. I faced a problem once I did the IM injection. Initially I was sure of what I was doing. However, once my teacher asked me why I needed to see blood, I realized the mistake I made. I felt confused and disappointed of how I can forget such a crucial step. Nonetheless, I fixed my mistake and was self-assured of how I managed the rest of the scenario.

Evaluation: Mostly, I did a very good job approaching and managing this patient. Initially, the patient was having a severe asthma attack and I managed her in accordance with the JRCALC(2013) guidelines. This was great. However, when I came to give the IM injection I made a really bad mistake, looking for blood to make sure I was in the muscle. Nonetheless, I fixed my mistake and that was good.

Analysis: The patient was initially suffering from a severe asthma attack. However, thinking about it, the patient was deteriorating as we were on our way to the hospital. I could have given the patient epinephrine, since she would have gone into life-threatening asthma. Nonetheless, my teacher said it was fine since we were close to the hospital. Also, for the IM injection, I’m not sure what happened but I messed up. Looking for blood would obviously mean I was in the blood vessel, and not in the muscle. When aspirating in the muscle I should see nothing going into the syringe. This will show me that I am in the muscle. Although it could be the nerve, this is very rare.

Conclusion: I could have been more careful and conscious when giving the IM injection, to avoid making the mistake I made. Also, I could have given the patient epinephrine just to save time, since she was continuously deteriorating. However, I believe I did everything else really well.

Action Plan: I plan to revise the procedure for IM injections, just to solidify it in my mind. Also, I plan to revise the dosages of the medications. Although I knew them all, I still have to revise them to memorize them perfectly. Finally I will manage this type of patient just as I did in this scenario. The only thing I plan to add is to give epinephrine if there is still time in the ambulance.

Learned Concepts:

This week we learned about acute inhalation emergencies. The first emergency was foreign body obstruction. The obstruction can be partial or complete. It can be laryngeal, subglottic, or aspiration (bronchioles and lungs).
80% of FBAO cases are pediatrics, most commonly in toddlers.
Complete airway obstruction leads to death.
Partial airway obstruction causes coughing, wheezing, chest pain, mucosal injuries, and bleeding. 
Aspirated foreign bodies cause lower airway obstruction. This leads to atelectasis, pneumonia, and decreased breath sounds.
Emergency treatment of aspirated FBAO starts with encouraging the patient to cough. Then if coughing ineffective and pt continues to chock, we use the Hamlick's maneuver. This maneuver is used in adults. In pediatrics we provide back blows and chest thrusts. If object is visible, can finger sweep it out. In obese and pregnant patients we use chest thrusts.
In infants we alternate between 5 back blows and 5 chest thrusts.
Symptoms of foreign body aspiration into tracheobronchial tree are respiratory arrest, stridor, wheezing, coughing, dyspnea.
Types of bronchial obstruction are:

• Bypass valve: Air passes in and out, no radiographic changes, and no symptoms
• Check valve: Air moves in but not out, results in obstructive emphysema
•  Stop valve: Both inspiration and expiration blocked, distal atelectasis results, and pneumonitis may occur

Esophageal foreign bodies include food or true foreign bodies. Most often they impact just below cricopharyngeous (just above clavicle). Once past the esophagus, most foreign bodies will pass through the GIT.

Clinical findings of this are dysphagia, odynophagia, stridor, choking, gagging, coughing, drooling, refusal to eat, vomiting, chest/neck pain.

Coin ingestion lodges in frontal plane in esophagus, and sagitally in trachea. Up to 30% of children with coins lodged in esophagus are asymptomatic.

Emergency removal of objects from esophagus is indicated when:

• Sharp object
• Button battery
• Bone fragement
• Complete obstruction
• Corrosive agents
• Any sign of esophageal perforation.

Swallowing button batteries is very dangerous because it leads to corrosion and esophageal perforation. This is due to the dissolution of the battery and heavy metal poisoning. The lethal dose of mercuric oxide is 0.5-1 g and there is 1-21g in a battery!!!

Nasal foreign bodies may present in children as extremely bad body odor, unilateral rhinorrhea, epistaxis, and sinusitis.

Angioedema is secondary to allergic reaction in majority of cases. Nasal intubation may be attempted or cricothyrotomy. If not, can administer hydrocortisone and epinephrine.

Drowning= death before 24 hours

Near drowning= death after 24 hours

Drowning can be wet or dry and in freshwater or saltwater. Freshwater takes away surfactant and saltwater destroys the walls of alveoli.

Aspiration can lead to aspiration pneumonitis, aspiration, pneumonia, ARDS and SIRS.

Inhalation of superheated air damages the upper airway but not the lungs. However, inhalation of extremely hot WET air causes thermal injury to the mucosa of the lungs and upper airway. Products of combustion can significantly injure alveoli. Methane and CO are produced in fires which displace oxygen from the alveoli and hemoglobin (CO affinity to Hb much higher than that of O2).

Smoke is incompletely combusted particles. The two main combustion gases are CO and cyanide. The number one cause of death related to fires is smoke inhalation. This occurs when products of combustion are inhaled. Some combustion products do not directly harm a person, but they take up the space that is needed for oxygen, such as in CO poisoning. CO poisoning is the leading cause of death in fires.

Hydrogen cyanide and hydrogen sulphide cause damage by interfering with the body's oxygen use at the cellular level. If oxygen delivery or use are inhibited, cells will die.

Image 1: Affect of smoke inhalation at alveolar level.

Shunt is when blood passes through the lungs without getting oxygenated.

Clues to smoke inhalation: Burns to face, singed facial hair, blistering inside mouth, sooty sputum, stridor, and brassy cough.

Symptoms include: cough, sore throat, SOB, increased RR, stridor, drooling, headache, eyes red and irritated, acute mental status changes, and skin color may range from pale to bluish to cherry red(classic sign of CO poisoning).

Airway burns require instant intubation. Use small ETT to avoid irritation of mucosa. If pt is concious -> RSI. If can not intubate-> cricothyrotomy.

Assessing such patients involves putting my safety first, then assessing the airway early, ausculate chest, look in nostrils and mouth, inspect sputum if cough is productive, and always remember SpO2 may be inaccurate (can say 100% but because of CO not O2).

Management of this patient is to remove the patient from the source of fire, provide oxygen, may need intubation, suction mucus and secretions, IV fluids, pain relief, close monitoring, and rapid transport. If cyanide poisoning, can use antidote amyl nitrate.

Three critical interventions:

1. Removal of victim from ongoing exposure
2. Establish airway
3. Delivery of oxygen

Any chemical leak is a safety concern and must be dealt with with caution. Some chemicals can cause burns such as HCl and SO2.

Organophosphates are the active ingredient in insecticides and nerve gas. Stimulates PNS by allowing unregulated action of acetylcholine at neuro-effector sites. Organophosphate is an anticholinesterase.

Signs and symptoms of organophosphates poisoning include bradycardia, excessive salivation, GI disturbance, excessive secretions, and bronchospasm. Can be remembered as DUMBEIS: Diarrhea, Urination, Miosis, Bronchospasm/ Bronchorrhea, Emesis, Lacrimation, Salivation.

Treatment with atropine (antiparasympathetic) with repeated doses until pupils dilate.

S&S of toxic inhalations: Rapid respirations, dizziness, confusion, headache, nausea, vomiting, respiratory distress, decreased LOC, blindness, seizures, cerebral edema, coma, arrhythmias, and possible burns in mouth.

In such cases must know the nature of inhalant, length of exposure, nature of environment (closed/open?), whether patient lost consciousness during exposure, and facial and airway signs and symptoms.

ABCs of toxic inhalation are safety FIRST! The must remove the patient upwind from environment. Must pay attention to patient's airway, provide oxygen, rapid transport, monitoring of vitals, and establish IV access.
After the lecture we discussed the tutorial case study.

Image 2: My notes of our discussion for Week 7 tutorial case study.

Additional Readings

To understand how to deal with patients i learned about this week, i opened my JRCALC (2013) and read the guidelines on how to act in the situations discussed. These include FBAO, dyspnea, burns and scalds, and CBRNE incidents.

Image 3: Highlighted points on managing FBAO in adults. Adopted from (JRCALC, 2013).

Image 4: Highlighted points on managing FBAO in children. Adopted from (JRCALC, 2013).

Image 5: Highlighted notes on guidelines for dyspnea. Adopted from (JRCALC, 2013).

Image 6: Highlighted notes of guidelines for burns and scalds in adults. Adopted from (JRCALC, 2013).

Image 7: Highlighted noted of guidelines for burns and scalds in children. Adopted from (JRCALC, 2013).

Image 8: Highlighted notes of guidelines for immersion and drowning. Adopted from (JRCALC, 2013).

Image 9: Highlighted notes of guidelines for immersion and drowning continued. Adopted from (JRCALC, 2013).

Image 10: Algorithm for approaching and managing patients at CBRNE incidents. Adopted from (JRCALC, 2013).

Image 11: Highlighted points about Atropine for managing OP poisoning. Adopted from (JRCALC, 2013).

I also read the recommended readings and found some interesting points.

The pathophysiology of drowning is as follows: Loss of breathing pattern ->  Panic and struggle-> Breath holding which leads to aspiration or laryngospasm and finally hypoxemia (Weinstein & Krieger, 1996).

It was interesting to read that the majority of FBAOs are cleared before EMS arrival. This shows the importance of teaching parents CPR and how to manage a child's airway (Andazola & Sapien, 1999).

References

Andazola, J.J.,& Sapien, R.E. (1999). The choking child: What happens before the ambulance arrives. Prehospital Emergency Care, 3, 7-10. doi: 10.1080/10903129908958897 

Join Royal Colleges Ambulance Liaison Committee. (2013). UK ambulance services: Clinical practice guidelines 2013(4^th edition). Bridgwater: Class Professional Publishing.

Weinstein, M.D.,& Krieger, B.P. (1996). Near-drowning: Epidemiology, pathophysiology, and initial treatment. The Journal of Emergency Medicine, 14(4), 461-467. doi: 10.1016/0736-4679(96)00097-2

Stand Out Moment

This week my stand out moment revolved around something i thought i understood, but did not. For the IM injection i thought i understood the procedure fully. However, this week i made a big mistake in this skill. I looked for blood upon aspiration, which is completely wrong. My teacher explained to me that that shows me i am in a blood vessel, and not the muscle. I will never forget this moment and now i am fully aware of what i need to look for when performing IMI and why.

Biggest Impression

My mistake when performing IMI made the biggest impression on me as a paramedic because i never want to do this mistake in my practice in the future. This situation will always remind me of how to properly perform IMI and why i should not find blood when aspirating.

Strengths and Limitations

My strength is my ability to manage an asthmatic patient. However, my weakness is in performing proper IMI. I will always keep my mistake and my teacher's explanation in mind. Also, i will practice this skill many times, until i am able to perform it really well, without any mistakes.