Ventricular Assist Devices

A ventricular assist device (VAD) is a mechanical pump that’s used to support heart
function and blood flow in people who have weakened hearts. There are two main types of VADs: Left ventricular assist devices (LVAD) and Bi-ventricular assist devices.  Regardless of the type of VAD that the patient has the assessment, treatment, and destination decision is vastly different for the VAD patient.

Question: You are called to the home of a 50 yo patient who states he feels weak and dizzy. The patient states that he received a VAD two months ago.  Your exam reveals the following: No radial or carotid pulse and no blood pressure.  Despite these finding the patient is talking to you. What does this mean? What do you do?

Follow the links below to learn more about VADS:

VAD info

ZOLL LifeVest Wearable Defibrillator

ZOLL Lifevest

 Interesting device that we may encounter..

The LifeVest wearable defibrillator is a treatment option for sudden cardiac arrest that offers patients advanced protection and monitoring as well as improved quality of life.
The LifeVest is the first wearable defibrillator. Unlike an implantable cardioverter defibrillator (ICD), the LifeVest is worn outside the body rather than implanted in the chest. This device continuously monitors the patient's heart with dry, non-adhesive sensing electrodes to detect life-threatening abnormal heart rhythms. If a life-threatening rhythm is detected, the device alerts the patient prior to delivering a treatment shock, and thus allows a conscious patient to delay the treatment shock. If the patient becomes unconscious, the device releases a Blue™ gel over the therapy electrodes and delivers an electrical shock to restore normal rhythm.

See the two links below for more information.

http://lifevest.zoll.com/medical-professionals/how-lifevest-works.asp

Medical-professionals/how-lifevest-works

http://lifevest.zoll.com/medical-professionals/first_responder_resources.asp

medical-professionals/first responder resources

INTRANASAL NALOXONE: A NEW WEAPON IN THE BLS ARSENAL - FDNY Journal

 

 

INTRANASAL NALOXONE: A NEW WEAPON IN THE BLS ARSENAL

Opioids are very effective medicines that are often prescribed for pain control. Consequently, they also have a high potential for abuse. According to the National Institute of Health, some of the most
commonly abused prescription drugs are codeine, morphine, methadone, and fentanyl. Overdoses
may occur unintentionally (e.g., a person took extra prescribed pill because she forgot she already had
taken one) or purposefully in an attempt to ‘get high’ or to attempt suicide. Since 1990, deaths related to opioid overdoses have more than tripled. 100 people die from drug overdoses every day in the United States. This opiate abuse epidemic has garnered much attention; and the public has demanded a response. For over 20 years, paramedics in New York City have been able to successfully treat and reverse the effect of opioids using naloxone. In the past three years, EMTs from other regions of New York State and other members of the public have received training in the administration of the opiate antidote naloxone. This journal will discuss how opiates work, the physiologic changes associated with opiates, how to assess and manage patients with suspected opiate overdose, and finally, we will discuss considerations when it comes to special populations and concerns when it comes to administering naloxone.

For the rest of the article click here: 



FDNY Naloxone Journal.pdf

Pharmacology Review

With the addition of Naloxone to the EMT Pharmacopeia  I thought it was a good time to post a quick review of the medications that EMTs are allowed to either administer or assist with.

Follow the link to see the handout.



Pharmacology review.pdf

Venomous Snakes

There are only three species of poisonous snakes living in the wilds of New York (many other kinds may be found in the homes of private individuals and, occasionally, escapes occur!). These are the timber rattlesnake, the massasauga (erroneously called "pygmy rattler"), and the copperhead. All three are uncommon. The timber rattlesnake (listed as "Threatened" by the New York State Department of Environmental Conservation) enjoys the widest range; it is found mainly in the southeastern part of the state, except Long Island and New York City, with scattered populations as far north as Lake George and also along the Southern Tier in western New York. Its populations have been severely reduced, primarily due to bounties and commercial capture for snakeskin products and the pet trade. The massasauga (listed as "Endangered") occurs in only two locations, both large wetlands. One is located northeast of Syracuse and the other is west of Rochester. This species is the subject of a cooperative research program between researchers at SUNY-ESF and NYSDEC. The copperhead is mainly found along the lower Hudson Valley south of Kingston and scattered through the Catskills.
The timber rattler and massasauga both possess a rattle at the end of their tails. It is made of a series of hollow scales that produce a distinct buzz when the snake vibrates its tail (a new one is added each time the snake sheds its skin, which may be several times a year). Both rattlers are sort of chunky snakes but the timber rattlesnake can attain lengths of up to six feet while the massasauga barely reaches three feet. A timber rattler's head is much wider than a massasauga's and there are numerous small scales on the crown of its head; the massasauga has nine larger scales on the crown. Copperheads lack the rattle, but will vibrate their tail when annoyed. In dry leaves, this vibration can sound like a rattle; many other species, such as milk and rat snakes, will also perform this behavior. The copperhead can be told by its coppery-red head and by the distinct bands along its body which are widest at the sides and narrowest across the back.

Rattlesnake bite

For more information on treatment follow this link:  


Jacobi Snakebite Protocol_2010.pdf

Small Copperhead - Wesley Hills, NY

Small Copperhead, Wesley Hills, NY

Northern Water Snake (non-venomus), Camp Dora Golding, PA

Large Eastern Copperhead, Kakiat Park, Rt 202, Suffern, NY

Eastern Timber rattlesnake - Harriman State Park, Tuxedo, NY

Eastern Copperhead, Tallman State Park, Nyack, NY

 

Eastern massasauga, Syracuse, NY

Vaginal bleeding in newborns

There was recently a EMS request for vaginal bleeding in a newborn female patient.  A call of this nature was unusual and caused much anxiety on the part of the EMS crew that responded. The child was taken to the hospital and was informed that this can be a natural occurrence in some newborn girls due to hormonal effects from the mother's hormones that crossed the placental barrier when the baby was in utero. It typically occurs on the third day after birth and may continue for a few days. Large amounts of blood are not normal for withdrawal bleeding. If bleeding seems excessive, vitamin K deficient bleeding or other coagulopathy should be considered.   In addition to the vaginal bleeding there can be temporary breast enlargement in both male and female newborns.

Hormonal effects in newborns

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Hormonal effects in newborns occur because, while they are in the womb, babies are exposed to many chemicals (hormones) present in the mother's bloodstream. After birth, the infants are no longer exposed to these hormones. This exposure may cause temporary conditions in a newborn.

Information

Hormones from the mother (maternal hormones) are some of the chemicals that pass through the placenta into the baby's blood during pregnancy. These hormones can affect the baby.
For example, pregnant women produce high levels of the hormone estrogen. This causes breast enlargement in the mother. By the third day after birth, breast swelling may also be seen in newborn boys and girls. Such newborn breast swelling does not last, but it is a common concern among new parents.
The breast swelling should go away by the second week after birth as the hormones leave the newborn's body. Do not squeeze or massage the newborn's breasts because this can cause an infection under the skin (abscess).
Hormones from the mother may also cause some fluid to leak from the infant's nipples. This is called witch's milk. It is common and usually goes away within 2 weeks.
Newborn girls may also have temporary changes in the vaginal area.

• The skin tissue around the vaginal area, called the labia, may look puffy as a result of estrogen exposure.
• There may be a white fluid (discharge) from the vagina. This is called physiologic leukorrhea.
• There may also be a small amount of bleeding from the vagina.

These changes are common and should slowly go away over the first 2 months of life.

Alternative Names

Newborn breast swelling; Physiologic leukorrhea

References

In: Kliegman RM,Behrman RE, Jenson HB,Stanton BF, eds. Nelson Textbookof Pediatrics.19th ed. Philadelphia, Pa: Saunders Elsevier; 2011: chap XX.

Update Date: 2/21/2013

Updated by: Neil K. Kaneshiro, MD, MHA, Clinical Assistant Professor of Pediatrics, University of Washington School of Medicine. Also reviewed by A.D.A.M. Health Solutions, Ebix, Inc., Editorial Team: David Zieve, MD, MHA, Bethanne Black, Stephanie Slon, and Nissi Wang.

Pediatric Angulated Fracture

Angulated fracture in young boy who fell off blow-up slide.  Distal perfusion was good.  Since distal blood flow was not compromised injury was splinted as found and patient was transported to hospital.


Question:  In NYS are EMT's allowed to attempt to straighten a severely angulated long bone fracture if distal perfusion is compromised?  Answer: YES

Recent question from an EMT student

Mottled arm

Mottled newborn

Hypoperfusion Question and Answer

Question: Good morning, just want to make sure I got it right, most emergencies have Hypoperfusion involve? (at least potentially) in other words, a dead person is in shock, so every life threatening situation is a shock situation, so all emergencies need to be treated for shock? (CHF, MI, CVA and even appendicitis can lead to shock) so, shock treatment is only needed if signs and symptoms of shock are present?

Answer: Not exactly.  Not every emergency results in hypoperfusion.  As an example. A person having an asthma attack is only having a respiratory emergency unless the hypoxia gets so severe it interferes with the ability of the heart to beat.   

A quick review of shock:

Hypovolemia is one for the four categories of shock.  This type of shock is caused by low volume of either blood (Hemorrhagic shock) or other fluid (Metabolic Shock).  Metabolic shock is caused by a loss of intracellular (inside the cells) or extracellular (outside the cells but not in the blood vessels) fluid.  Metabolic shock is usually caused by excessive vomiting, diarrhea, urination in Diabetic Ketoacidosis (DKA) and renal failure. It can rarely be caused by excessive sweating. Some books list plasma lost from burns as hemorrhagic shock and other list is as metabolic.  Usually it is considered metabolic shock.  Treatment of hemorrhagic shock involves the controlling of external bleeding, leg elevation, O2, and temperature control (keeping the patient warm).  Transport should be immediate and to a trauma center. Treatment of metabolic shock involves leg elevation, O2, and temperature control (keeping the patient warm).  Transport can be to any hospital, but if involves a pediatric patient it should be to a pediatric capable hospital. Hypovolemic shocks are the only shock that result on fluid being lost from the body. 

Cardiogenic shock is caused by one of four issues.  1.  Severe damage to the ventricles.  This can be caused by an AMI (heart attack), infection in the myocardium (heart muscle), or rarely trauma to the myocardium.  2.  Heart valves not working correctly and allowing blood flow to go backwards. 3.  A heat rate that is to slow (bradycardia) or a heart rate that is to fast (tachycardia).  When the heat rate is to slow the Cardiac Output (heat rate x stroke volume) drops because the number of time the ventricles are pumping is to slow.  In a tachycardia the problem is that the time between contractions (diastole) is so short the ventricles do not fill completely so stroke volume drops.  This is called decreased ventricular filling time.   EMT treatment involves O2 (sometimes the patient’s mental status will be so decreased that you can use the BVM), warmth, and rapid transport.

Distributive shock involves the smaller more peripheral blood vessels in the body.  The cause of hypoperfusion is the sudden vasodilation (widening) of these blood vessels. There is no blood loss; the blood is re-distributed from the vital organs to the skin and other non-vital area.  The result is that there is less blood going to vital organs.  Distributive shock is considered the most difficult shock to determine.  The reason why is as follows.  In all other shocks the skin is usually cool, pale, and diaphoretic.  Peripheral pulses are usually weak.  In distributive shock, the warm core blood is sent to the extremities and surface blood vessels.  Initially, the skin will be warm, pink (in light skinned patients), and dry.  The peripheral pulse will be strong. This will change if the shock is not treated. There are four types of distributive shock:

1.       Anaphylactic shock.  Caused by the body’s immune system overreacting to some foreign substance.  (Bee venom, peanuts, milk, medications etc.) Substances are released by the immune system that causes vasodilation and bronchoconstriction.  The is also an increase in the ability for plasma to leak out of the capillaries (increased capillary permeability) which results in hives (urticaria) on the skin and possible narrowing of the airways.  Treatment involves the use of the EPI-Pen, O2, and transport.

2.       Septic shock is caused by vasodilation which is caused by a severe body wide infection. Usually in the blood stream and major organs. There can also be an increase in capillary permeability like in anaphylaxis.  Treatment involves warmth, O2, leg elevation and transport.

3.       Neurogenic shock is the rarest form of shock.  It is also called spinal shock.  The usual cause is damage to the spinal cord.  This results in interruption of the sympathetic nervous system (Fight or flight). The sympathetic nervous system usually results in vasoconstriction and tachycardia.  If it is interrupted the parasympathetic nervous system will dominate causing vasodilation and bradycardia.  Neurogenic shock is the most difficult of all of the Distributives shocks to diagnosis.  This is because in addition to the other tricky presentations (warm, flushed skin and strong radial pulses) there is also a slow to normal pulse rate.  In the other shocks we expect there to be a tachycardia to compensate for the low perfusion. .  Treatment involves warmth, O2, Leg elevation and transport.  Since there may be paralysis of the muscles of the airway and breathings from the spinal cord injury you may need to maintain the airway (airway adjuncts) and ventilate the patient.

 4.       Psychogenic shock (simple fainting, syncope) results from the vagus nerve being stimulated.  The vagus (10th cranial nerve) is the messenger nerve of the parasympathetic nervous system. When activated it causes a slowing of the pulse and vasodilation resulting in a drop in blood pressure.  This results in less blood to the brain which causes syncope (fainting); the patient becomes unconscious and usually falls supine or prone.  It is now easier for blood to reach the brain then when the patient was standing.  The patient gradually wakes up as the heart rate increases back to normal and the blood vessels go back to normal diameter.  This usually causes the cerebral (brain) hypoperfusion to end. The patient usually has no long-term issues, unless they hurt themselves when they fainted.  EMS can cause Psychogenic Shock to happen by suctioning and /or inserted an OPA too roughly and by pressing to hard when checking a carotid pulse.  Patients can cause this to happen by straining when they go to the bathroom.  Sometimes this happens as a result of stress, bad news, and even the sight of blood. Treatment involves checking the patient for injury, leg elevation, O2, and warmth.  They should be brought to hospital to determine the cause of their syncope.

Obstructive shock is cause by a blockage (obstruction) in a large blood vessel.  Again, there is no loss of blood but rather blood flow through the circulatory system is slowed and may even be stopped.  Common causes include Tension Pneumothorax, Pulmonary Embolism, 3rd trimester pregnant females lying supine, and Cardiac Tamponade.

1.   In a tension pneumothorax pressure builds up in the thoracic cavity outside of the lungs and decreases blood flow through the inferior and superior venae cava. This results in less blood getting back to the heart, which results in less cardiac output.   Usual causes are a puncture or hole to the lung.  This can be caused by penetrating trauma from a bullet, knife or even a broken rib.  Rarely a patient’s lung can burst without trauma; this is called a spontaneous pneumothorax. Signs and symptoms include diminished or absent lung sounds over the injured lung, tracheal deviation away from the injured lung (also called a mediastinal shift, this is usually an x-ray finding), difficulty breathing, tachycardia, and in severe cases hypoperfusion.  In there are any holes between the patient’s shoulders and umbilicus (belly button) they should be sealed with an occlusive (airtight) dressing on 3 sides.  This stops air from being inhaled though the hole on patient’s chest into their thoracic cavity when the patient inhales but allows pressure to vent from the thoracic cavity when the patient exhales. O2 should be administered and the patient should be brought to a trauma center.

2.   Pulmonary Embolisms result in a blockage somewhere in the pulmonary arterial circulation.  This results in lees deoxygenated blood in reaching the lungs.  Patients complain of a sharp pain to their chest and difficulty in breathing. There is no blockage in the airway.  The sensation of shortness of breath (SOB) comes from the restriction of blood flow to the lungs.  Common causes are recent fractures, being bed ridden (confined to a bed), deep vein thrombus (DVT) of the legs.  There is an increased risk in women who smoke and take birth control pills (oral contraceptives).  It could also happen in scuba divers from breathing compressed air while underwater and then coming to the surface too quickly. Management on a BLS level is limited to O2 and rapid transport.

3.   Supine Hypotensive Syndrome. In a third trimester pregnant women who lies supine the weight of the baby may compress the inferior vena cava causing less blood to get back to the heart.  This is usually not an emergency.  EMS can cause this to happen by placing the patient supine as in spinal immobilization.  Treatment is as simple as moving the patient onto their left side or tipping the long board on the left side slightly.

4.   Cardiac Tamponade is when the sac (pericardial sac) surrounding the heart has a buildup of fluid in it.  This fluid can be either blood from trauma or other fluids that build up from infection. It can rarely be caused by a rupture (burst) coronary artery. (This usually fatal) This fluid buildup does not allow the ventricle to fully expand and fill with blood.  This results in decreased cardiac output.  Signs and symptoms may include: In trauma – puncture wounds to chest, jugular vein distention (JVD), diminished or muffled heart sounds (JVD).  Depending on the amount of fluid in the pericardial sac there may be signs and symptoms of shock.  In an infectious (pericarditis) form of Cardiac Tamponade the patient will usually appear ill from an infection.  They will be complaining of pain on their chest, SOB.  There sign may be warm if they have fever or cold if they are in shock.  In severe medical forms of Cardiac Tamponade there can be muffled heart sounds and JVD. In trauma; treatment incudes sealing any holes on the chest (in case there is also a tension pneumothorax), 02, and rapid transport to a trauma center.  In medical; treatment includes O2 and transport.

Ok.  I guess it was not a quick review.

Thanks,

Frank