Components of blood – 45% RBC (hematocrit – 48% men/ 38% women), 54% Plasma, 1% WBC and Platelets

Blood tests:

Hemoglobin (Hgb) usually around 14  (Varies for men and women, adults and children)

Hematocrit is (Hct) usually about three times Hemoglobin levels,

Platelet count usually between 150,000 and 450,000 per uL of blood

CBC – Complete blood count

Diff – Measures percentage of different types of white blood cells (differential hematology blood analyzers)

92% of blood plasma is water, 6-7% Proteins, remainder includes clotting factors, glucose, and electrolytes

Contains 3 Important proteins

Albumins – keep water in blood – low proteins will let water leak out – edema – (seen in poor nutrition, elderly, etc)

Immunoglobulins – immune system response

Fibrinogens – for blood coagulation

 

Red Blood Cells

Most abundant cells in body

Primarily responsible for tissue oxygenation

White Blood Cells

Cells of the immune system, also called leukocytes, 5 types exists. Produced in Bone Marrow. Elevation of WBC count indicative of disease.

Arterial Blood Gas Levels (ABGs)

• Partial pressure of oxygen (PaO2) – 75 – 100 mmHg
• Partial pressure of carbon dioxide (PaCO2) – 35 – 45 mmHg
• A pH of 7.35 – 7.45
• Oxygen saturation (SaO2) – 94 – 100%
• Bicarbonate – (HCO3) – 22 – 26 mEq/L

Note: low HCO3 decreases the effectiveness of many drugs – specifically epinephrine.

I figured I’d write one Mnemonic to help remember all the other acronyms we use. (Not in order but what the heck! – Each one has the full description below) Enjoy!

Mamas Dogs Flips

M – MONA

A- ABC DEF GO

M- MOIST N DAMP

A- AEIOU TIPS

S- SAMPLE

D – DCAP BTLS

O- OPQRST

G- GUT PAINS

S- SIFDO

F – FAST

L- LEAN

I – IPASSO

P- PERRL

S- SLUDGEM

MONA – For ACS – Morphine, Oxygen, Nitrates, Aspirin

ABC DEFG – Airway, Breathing, Circulation, Disabilities, Extremities/Expose, Full set of vitals, GO!

MOIST N DAMP – For CHF –

Morphine
Oxygen
Intubation
Sit-up
Twelve lead
Nitrates
Dangle legs
Ativan (lorazepam)
Monitor Q 3-5
Pulmonary Congestion (CPAP)

AEIOU TIPS – AMS/Seizures

Alcohol

Epilepsy

Infection

Overdose

Uremia

Trauma

Insulin

Psychosis

Poison

Stroke

SAMPLE – Signs/Symptoms, Allergies, Medications, Past History, Last oral intake, Events leading up

DCAP BTLS – Deformities Contusions Abrasions Punctures/Penetrations Burns Tenderness Lacerations Swelling

OPQRST – Onset, Provokes/Palliates, Quality, Radiation, Severity, Time

GUT PAINS – (For Abdominal Pain)

G- Gallbladder, Gas, Gastritis,Gynecological
U- Ulcer
T- Trauma such as ruptured spleen, etc.
P- Pancreatitis, PID, Pregnancy (ectopic), Perforated Ulcer
A- Aortic Aneurysm, Appendicitis, Abdominal Angina
I-  Intestinal Obstruction, Infection, Ischemia of the bowel
N- Neoplasm
S- Spasm of the esophagus, Splenic rupture

SIFDO (Order of exam) Scene Size Up, Identify life threats, Focused Exam, Detailed Exam, Ongoing Assessment

FAST – Neuro assessment for Stroke/CVA – Facial paralysis, Arm weakness, Speech difficulties, Time to act

LEAN – Meds that can given down the ET tube. Lidocaine, Epi, Atropine, Narcan

IPASSO – Inspect, Palpate, Auscultate, Stabilize, Seal, Oxygen

PERRL – Pupils Equal Round Reactive to Light

SLUDGEM – Organophosphate exposure, Salivation, Lacrimation, Urination, Defecation, Gastric Upset, Emesis, Miosis

Ok, so i cheated.. I used this anagram creator to come up with the word; you can plug in these letters and choose from 1000 other variations. (saiosafdmmsplg)

This pharmacology booklet was handed out the other night, it is very useful and comprehensive. This was originally prepared for the St Vincent’s class and any references to protocols refer to NYC REMAC (as of 2006).

Sample page:

_________

También encontré un gran recurso si usted está buscando para comprar en línea de equipos médicos. Ellos llevan las máquinas de EKG, máquinas de ultrasonido, así como desfibriladores

By Miguel

"This is why people fail exams and/or lose their certifications"

Rule #1: BLS before ALS.

Rule #2: Treat your patient not the monitor.

Rule #3: An ‘excellent’ EMT = a ‘good’ medic.

Rule #4: Protocols are guidelines, not set in stone.

Rule #5: Refrain from getting tunnel vision.

Never forget:

1) ABC DEFG (airway, breathing, circulation, disabilities, extremities, full vitals, GO).

2) IPASSO (inspect, palpate, auscultate, stabilize, seal, O2).

3) OPQRSTI (onset, provocations, quality, radiation, severity, time, interventions).

4) SAMPLE (signs/symptoms, allergies, medications, past hx, last intake, events).

5) Pertinent questions regarding call: ex: weight, LMP, PARA, Gravada, drug consumption, Etoh, smoking, etc.

* Head to toe assessment *

** approximately 40 questions before you begin ALS, unless the call is obvious **

Rookie Mistakes:

#1 Uses monitor for everything.

#2 Every call becomes ALS.

#3 Every chest pain is cardiac.

#4 Every patient gets an IV.

** don’t go by what the EMT’s tell you **

***Become a Clinician***

Been a while since we did cardiology so I wanted to do a quick review on the normal deflections you should expect to find in each lead of an EKG

Limb Leads

Lead I – Looks across top of heart with positive electrode at left arm – so QRS complexes are upright but not that tall

Lead II – Follows normal electrical axis of heart, top right to bottom left . All complexes should be upright and tall.

Lead III – Looks from top left towards bottom left – at this angle P waves may be inverted but QRS should be upright (more than in lead I)

Lead aVR – Positive on right arm, so everything negatively deflected

Lead aVL – Positive on left arm – similar to Lead I but this lead looks down AND to the right so QRS are upright but very small

Lead aVF – Positive at left leg, looking at bottom of heart. Electricity is coming right at this lead so QRS should be upright and prominent.

 

Chest Leads

Leads V1-V6 – R wave starts very small and S wave is prominent. As the leads progress the R wave is more prominent and S wave is gone in V6. This is known as R wave progression.

  P Wave

P wave should be upright in Leads I and II as well as V3-V6

P wave always inverted in aVR

P wave usually upright in aVF and V3 but occasionally biphasic or flat

P wave is variable in leads III,  aVL, V1 and V2 (upright, inverted, biphasic)

Inverted P wave in II, III and aVF and upight in aVR is diagnostic for a Junctional or low ectopic atrial rythm.

Most people say that your best view of the P wave is in Lead II – others say V1. The truth is that every patient is different, find the best one on your patients EKG and study that one well.

 

See this page for some quick review and this page

NYC 911 System – Sat night 21:00 – 09:00

I had two "good" calls on Sat night

16 y/o female, pedestrian struck by a cab. Unconscious with agonal respirations. Paddles applied shows sinus tach at 174 but no palpable carotid or radial (PEA?). CPR performed for approx two minutes and faint pulses felt. We arrived same time as BLS, we were on scene for under 5 and had her in Belleview in about 12 minutes from going on scene. Attempted to intubate but unable due to blood and vomit (preceptor). Our brief exam revealed a flail chest (could I have done that with cpr?), distended abdomen, bruising to tib/fibs and ankles. I was asked to bag the patient in the ER so I got to observe them put in two chest tubes as well as the rest of the trauma team workup. (Got to watch an abdominal ultrasound with a Sonosite Titan) She was off to OR within 20 minutes of our arrival. Checked back later and her biggest problem seems to be an ICP of 35 and a probable Diffuse Axonal Injury. Not good, even if she makes it…

2nd call dispatched at 02:50 for an unconscious lying by his car. Talk while enroute was of a probable intox or OD. Arrive on scene at parking garage and told that vehicle was seen driving in at around 02:00 and he was found lying next to the open drivers door of his still running vehicle at around 02:40.

As we ran up the ramp we could see an elderly male lying on the floor looking everything like an arrest, as we got closer though we could hear loud snoring respirations. Assessment reveals HR 48 regular, respirations of 24, GCS 3, Pupils fixed and dilated, no obvious trauma. Loaded him into bus and worked out the differentials. Dilated pupils and Tachypnea – Not an opiate OD, Glucose at 79 so not likely that either. BP at 220+ with fixed and dilated pupils – likely a massive CVA. (We did not have time to do a 12 lead EKG)

I asked if I could intubate, I was told that I have one try. He was breathing so everything was moving and I didn’t get a good visual but tried to aim for where I thought it was but I didn’t push it far enough in. I wanted a second shot but we were at the hospital and he didn’t let me (I consoled myself later when I saw the resident take 10 minutes and a bougie to get it done)

At Belleview again they worked up a stroke code and Dr Chung literally forced us to stick around for the results of the CT. He spent quite some time with us going over the pedestrian struck patient’s CT and then again when the results of the second CT came back. Massive intracranial bleed – ventricles entirely filled with blood – also not good for this guy. If any of you meet this Dr just hang on to him, he really treated us like part of the team and explained and showed everything.

Other than that we had 1 Anxiety, 1 A fib (who vomited all over me) and 1 severe chest pain (probable gall stone per ED staff) Wind chills under 0 degrees F all night.

Good stuff

Dr Trowers

Epidemiology

• over 4 million poisonings annually
• 10% of ED visits and EMS responses
• 70% of accidental poisonings occur in children under 6 years old
• 80% of attempted suicides involve a drug overdose

Routes of Exposure

• Ingestion

• Household products
• Petroleum based
• cleaning agents
• cosmetics
• drugs, plants, or foods
• absorption occurs in stomach and small intestine

• toxic gases, vapors, fumes, aerosols (cyanide)
• carbon monoxide, ammonia, chlorine
• tear gas, Freon, nitrous oxide, methyl chloride
• carbon tetrachloride
• absorption occurs via capillary-alveolar membrane in the lungs
• SCENE SAFTEY IS PARAMOUNT – DO NOT GO IN WITHOUT PROPER PPE

• recognize poisonings promptly
• assess patient thoroughly to id the toxin and measures to control it
• initiate standard treatment procedures

• protect rescuer safety
• remove patient from toxic environment
• support ABCs
• monitor vitals signs closely
• reduce intake (wash skin, remove from environment, activated charcoal, etc)

• involve law enforcement
• involve medical control
• know local procedures and laws

• what
• when
• how much
• did you drink alcohol
• have you attempted to treat yourself
• have you been under psychiatric care? Why?
• what is your weight

To be continued…….

Some quick observations that made my life a bit easier when trying to calculate weight based dosages. Really pretty simple but once you reframe your mind this way it does tend to make life a bit easier.

Tip one: Use percentages instead of an absolute number.

• Example 1: 0.1mg/kg of a drug is really the same thing as saying 10% of patient’s weight in kg. So for example – you are ordered to give 0.1mg/kg of Morphine to a patient weighing 70 kilos – 10% of that is 7mg – simple.
• Example 2: 0.01mg/kg of a drug is the same as saying 1% of the patient’s body weight, which is also the same as saying 10% of 10% . So if you are ordered to give 0.01mg/kg of epinephrine to a 25 kilo patient yields… 10% is 2.5mg and 10% of that is 0.25mg – your dose.
• Example 3: 0.25mg/kg is the same as saying 25% of the patient’s weight. So if ordered to give 0.25mg/kg of diltiazem to an 80 kilo patient – your dose is simply 20mg

Tip two – drip rates

When you are trying to calculate your how fast to infuse your fluids, the following may be handy

• A 10gtts/ml drip set, set to one drip per second will yield 6ml per minute or 360 ml per hour,
• Increase the rate to two gtts per second and you are now running at 12ml per minute or 720ml/hr –

• (KVO rate is approximately one drip every two seconds which yields 3ml/min or 180ml/hr)

• You are ordered to give 2gm of mag sulfate in 50ml of NS over ten minutes. After adding the 2gm to the bag, you calculate as follows…I need to give the 50 ml over ten minutes which requires that I give 5ml per minute (50/10) so if one gtt/sec gets you 1ml/min – easy, you need 5 times that rate – or 5 gtts/sec to give your 50ml over ten minutes.

Pretty basic stuff that you may find helpful.

Great page here

Dr Trowers

Seizures

Sudden uncoordinated electrical activity in the brain

Generalized Seizures

• Petit mal, most common in ages 4-12, rarely after 20. typically less than 15 seconds, no postictal phase.
• Grad Mal – tonic/conic – often  preceded by aura, can occur at any age, typically followed by postictal phase. Can progress to status epilepticus (seizure lasting longer than 5 minutes or back to back seizures with no return to consciousness)

• Tonic – body wide rigidity
• Clonic – rhythmic contraction of major muscle groups,

Partial Seizures (Focal)

• Simple partial seizure – Jacksonian March seizure – tonic/clonic active localized to one part of the body – may spread and progress to a generalized seizure – No aura or LOC
• Complex partial seizure – mood changes, abrupt rage , often preceded by aura, 1-2 minutes, no postictal phase.

Seizure Management

• Protect from injury
• maintain airway
• provide oxygen
• establish vascular access
• emotional support and transport
• Meds (NYC REMAC Protocols)

• dextrose 25gm IVP (50% Solution)

• (Peds: glucagon 1mg IM, dextrose 0.5gm/kg IVP – > one month old use 10% solution, 25% for patients 1 month to 14 years)

• (Peds: Medical Control option: 0.05mg/kg IV/IN over two minutes)

• (Peds: Medical Control option: 0.1mg/kg IV/IO over two minutes, if no IV 0.5mg/kg via rectum)

• (Peds: if no IV 0.1mg/kg IM/IN max dose 5mg)