Week 11

Reflection:

Using the Gibb’s Reflective Model I will reflect on the tenth Lab session we had for this semester. It took place on the 11th of  November.

Description: This week in the morning when we arrived we practiced calculating a drip rate and preparing an IV set, priming it and actually counting the drip rate in the chamber. Later on in the day we practiced this skill again and added to it administering drugs. We practiced administrating Morphine in the Y port and the 3 way tap. Later on we worked through the defibrillation workbook. After that we discussed defibrillation, shockable rhythms, identifying them and the steps to performing safe and effective defibrillation. We also talked about the benefit of pads compared to paddles. Proceeding that we looked at the OSCE marking sheet for defibrillation and went through it step by step with our teacher.

In the second session we practiced setting up an IV and administrating drugs again. After that we looked through the OSCE sheet for IV preparation and drug administration. Following that our teachers assessed us on this skill against the OSCE sheet, in preparation for our OSCE next week. Proceeding, we practiced out approach to the cardiac patient. I was given a 50 yr old female with chest pain and a history of angina and HT. I followed the systematic approach and asked questions pertaining to history taking using PQRST  and conducted a VSS. The VSS included an ECG, which I asked for a 12-lead when the 3-lead showed a normal rhythm. Also, I took the SpO₂ , BP, and HR. The patient was hypertensive but everything else was normal. After that I decided to transport the patient due to increasing pain. On the way to the hospital I continued taking the patient’s history using SAMPLE.

Feelings: I felt really excited in these two lab sessions. They were so much fun. I felt confident with my IV setting up and administering Morphine and in the second session, I felt even more confident and excited. Learning about defibrillation and working through the workbook for it was really interesting for me. I felt really intrigued by this skill and felt relaxed when we were going through the OSCE sheet, since it was very simple. In the scenario I felt confident, put together, and I felt really good at the end of it, since I did much better than the week before.

Evaluation: The whole session was a good experience that helped restore my confidence and reminded me of why I love this profession.

Analysis: After this week I realized that I must mess up in order to do better the next time. It has been a real learning experience for me.

Conclusion: The only thing I would have done differently is provide analgesia to the patient while transporting her.

Action Plan: Review the IV and defibrillation OSCE sheets. Also, I plan on researching Morphine and learning more about it, such as its dose, contraindications and effects.

Picture 1: Administering Morphine in the Y port

Domain Knowledge:

Heart failure, also known as chronic heart failure, is when the heart is unable to pump adequately to meet the needs of the body. S&S: SOB, paroxysmal nocturnal dyspnea, leg swelling, and exercise intolerance. It is caused by MI, HT, Valvualr disease, ischemic heart disease, and cardiomyopathy. In the failing heart Starling's law does not apply to the heart. If preload increases too far the failing heart can not maintain output and the ventricles will fail.

Ejection fraction= SV/EDV x100. Where SV= EDV-ESV

Normally around 60%, in heart failure it drops below 40%.

Concepts for treating HF includes reducing the preload and afterload.

Treatment includes: Medication, such as vasodilators and diuretics, pacemaker, ventricular assist device, and heart transplant.

Increased venous return -> increased preload and afterload -> Acute LVF (pulmonary hydrostatic pressure overcomes plasma oncotic pressure.)

Results in increased Pulmonary pressures. If MAP is over 25mmHg, hydrostatic pressure starts to overcome oncotic pressure. This causes fluids to shift from pulmonary capillaries to the interstitium and then into alveoli causing alveolar flood-> Acute pulmonary oedema (APO)

Paramedics can have a significant effect on APO. Nocturnal dyspnea due to increased venous return, non-compliance with diuretics or anti-hypertensives, and increased fluid intake at night. Upon auscultation, paramedics can hear wheezes due to the fluid in the interstitium, fine crackles (fluid in alveoli), Alveoli can collapse due to loss of surfactant, this can be heard as fine crackles upon inspiration.

Prehospital treatment includes: Oxygen, GTN to decrease afterload, Morphine, continuous positive airway pressure ( CPAP), Frusemide. Patient with LVF or APO should never be allowed to walk, exertion must be a minimum.

CPAP maintains intra-thoracic pressure to keep airways open and maintain gas exchange. Patient must spontaneously ventilate. If have respiratory failure -> intubation.

Right ventricular failure (RVF) results from chronic LVF, or can be due to RV infarct, pulmonary valvulopathy, or cardiomyopathy. It causes peripheral edema, hepatosplenomegaly, and jugular venous distension due to increased preload. 

Cardiogenic shock is persistant hypotension and tissue hypoperfusion caused by cardiac dysfunction in the presence of adequate intravascular volume and left ventricular filling pressure. Has a high mortality rate,Caused by AMI, cardiomyopathy, spesis, myocarditis, dysrhythmmias leading to impaired diastolic filling, metabolic abnormalities, papillary muscle rupture, PE, Cardiac tamponade, and valvular disorder.  Can also be caused by inferior and anterior AMI. If during an ECG the rhythm looks normal but the patient doesn't -> perform 12 lead ECG.

For cardiogenic shock treat the cause if possible.

Enquiry and Research: 

Systolic dysfunction is the most common cause of heart disease in Western societies. Although both sysolic and diastolic CHF coexist, it is very important to distinguish between them when it come to treatment. The best treatment, however, is patients learning to manage their CHF . This is done by restricting fluid intake, adhering to a complex medication regimen, maintaining a low sodium diet and engaging in physical activity. Also, evidence suggests the benefits of using biventricular pacing in HF to resynchronise cardiac contraction and improve ventricular performance (Massey & Williams, 2011).

I read further on the different causes of HF. The following are the bits i found helpful:

Picture 2: Mechanisms of atherosclerosis and persistent HT on HF. Adopted from ( Marieb & Hoehn, 2014).

Picture 3: Mechanisms of multiple MIs and dilated cardiomyopathy on HF. Also, results of LHF. Adopted from ( Marieb & Hoehn, 2014).

Picture 4: Results of RHF. Adopted from (Marieb & Hoehn, 2014).

It is uncommon for patients with HF to have a normal ECG. Therefore, if the ECG is normal an alternative diagnosis must be considered.

Also, mentioned earlier GTN and furosemide are used to treat HF. However, prehospital trials comparing administration of furosemide vs. GTN and found that GTN was better. Therefore, furosemide must only be given after nitrates (JRCALC, 2013).

Picture 5: Algorithim for HF. Adopted from (JRCLAC, 2013). 

Morphine presents as an ampule with 10mg/ ml. It is a strong opioid analgesic. It depresses  respiration and induces hypotension. Given via IV route and needs 2-3 minutes to start acting. Reaches its peak between 10-20 minutes. Morphine should be diluted with 0.9% normal saline to make a concentration of 10mg/10ml. Start with minimal dose and increase by 2 mg every 3 minutes if pain doesn't go. Maximum dose is 20 mg! (JRCALC, 2013).

Picture 6: C/I of Morphine. Adopted from (JRCALC, 2013).

 References

Joint Royal Colleges Ambulance Liaison Committee. (2013). UK ambulance services: Clinical practice guidelines 2013. Bridgwater, England: Class Professional Publishing.

Marieb, E.N, & Hoehn, K.N. (2014). The cardiovascular system: The heart. In E.N. Marieb & K.N. Hoehn (Eds.), Human anatomy and physiology (713-741). Essex, England: Pearson Education.

Massey, S.L., & Williams, B. (2011). Cardiovascular emergencies. In K. Curtis & C. Ramsden, Emergency and trauma care for nurses and paramedics (489-533).Chatswood, NSW: Mosby