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Acute Flash Pulmonary Edema Scenario InformationTitle:Congestive Heart Failure Date Created:February 10 2016Target Audience: FORMCHECKBOX PCP I FORMCHECKBOX PCP II FORMCHECKBOX PCP FORMCHECKBOX ACP FORMCHECKBOX CCPScenario Author:Will JohnstonAuthor Contact:c_johnston37@fanshaweonline.caScenario OverviewParamedics are called code 4 in the middle of the night for a 56 year old female acutely short of breath. On arrival the Paramedics find the patient extremely short of breath and diaphoretic. The patient’s husband reports that the patient was hospitalized for a similar incident 3 weeks ago and had to be intubated. The patient has diffuse coarse crackles in all lung fields. The patient should be treated with CPAP or BiPAP as well as sublingual Nitroglycerine. Scenario Objectives, Summary, NOCPS, and ExpectationsLearning Objectives:React to changes in patient conditionsEmploy proper judgement in management of severe pulmonary edemaEmploy proper anaphylaxis management and treatmentAssociated NOCPs 4.5.n – Obtain 12-Lead electrocardiogram and interpret findings5.8.h – Administer medication via the sublingual route6.1.a – Provide care to patient experiencing signs and symptoms involving the cardiovascular system6.3.a – Conduct ongoing assessments based on patient presentations and interpret findings 6.3.b – Redirect priorities based on assessment findingsParamedic GRS1 Expectations:Situational Awareness: recognize the seriousness of patient conditionHistory Gathering: use the husband to get a full patient history Patient Assessment: thorough examination including respiratory and cardiovascular assessmentDecision Making: early decision to administer CPAP and NitroglycerineResource Utilization: utilize patient’s family for history Communication: effective crisis communication with patient and family Procedural Skill: proper 12 lead placement, Nitroglycerine administration, and CPAP application Tavares W, Boet S, Theriault R, Mallette T, Eva KW. Global rating scale for the assessment of paramedic clinical competence. Prehospital emergency care. 2012 Dec 5;17(1):57-67.Scenario PreparationPatient RequirementsMoulagePatient InstructionsCyanosis to patient’s lips (blue makeup)Patient is extremely diaphoretic (sprayed with water)Patient is extremely short of breath and one word dyspneicPatient can answer questions but very slowlyPatient tells Paramedics that he ‘can’t breathe”Additional Equipment and PropsPropsEquipment ChairTableGlass of waterBLS BagMonitor/DefibrillatorSymptom relief kitOxygen bagScene Set-UpThe patient should be siting at a table hunched over in a tri-pod like positionHusband greets Paramedics at the door Bystander Husband can communicate all of patient’s medical information and historyDispatch Information Code 4 to a home for a patient short of breath, history of heart problems, FRI negative with a cough. Patient Information Patient Name: Stephanie Sagoda Age:56Weight: 55gGender: FemaleChief Complaint: Short of breathHistory of Present: Patient awoke approximately 20 minutes prior to call for Paramedics with extreme shortness of breath. Patient was hospitalized 2 weeks prior from a similar incident for which he was intubated. SAMPLE History: AllergiesNKA MedicationsASA, Atrovent, Carvedilol, Clopidogrel, Crestor, Furosemide, LansoprazolePast HistoryCABG 6 months prior, CHF, Renal Failure, HTN, High CholesterolOral IntakeNormalOPRST (If Applicable) OnsetUnable to determineProvocationUnable to determinePalliationUnable to determineQualityUnable to determineRadiation Unable to determineSeverity Unable to determineTimeBystanders state approximately 10 minutes prior to arrivalAdditional InformationPatient should be getting increasingly short of breath throughout the callPhysical FindingsPrimary Survey:AirwayProfound cyanosis to the lips and face BreathingShallow and laboured breathingCirculationRapid central pulses, pale, warm skin Auscultation Crackles throughout all lung fieldsDistal PulsesWeak distal pulsesShockDiaphoretic, warm, pale Secondary Survey :Head Some cyanosis to lipsNeckUnremarkableChestShallow but equal chest rise and fall BackUnremarkable PelvisUnremarkable LegsUnremarkable ExtremitiesNo edema, weak peripheral pulses Vital Signs, Expected Actions, and ModifiersPatient states change throughout the scenarios. Generally a scenario will include 3 patient states. You may have more than 3 patient states if you have a very dynamic scenario or if there are a number of potential patient modifiers. Patient State 1:State: BaselineTRIGGER: Start of the Scenario Vital Signs Expected ActionsHR130Good primary assessment consisting including auscultation History taken from wife, minimizing need for patient to talk Oxygen administeredNitroglycerine administered as per local protocolsCPAP Administered as per local protocols SPO279% (84%) BP204/140RR48CO2 22Temp37.4Skindiaphoretic,PaleGCS15Pupils+ +BGL5.1ECGSinus Tach12 LeadSinus Tach Modifiers If oxygen is administered increase O2 saturation to 84%Nitro and CPAP administered saturations increase and remain at 84%No Nitro or CPAP by 6:00mins move to State 3Trigger Nitro administered (State 2) Or Scenario ends at 12:00 minutes Patient State 2: State: Post- Nitro/CPAPTRIGGER: Nitro AND/OR CPAP is administered Vital Signs Expected ActionsHR136Nitro every 5 minutes as per local protocols CPAP titrated every 5 minutes Patient transported in a semi-sitting positionIV started as per local protocols Patient denies any relief from either CPAP/NITRO or a combination of both SPO284%BP180/104RR48CO226Temp37.4Skindiaphoretic,PaleGCS15Pupils+ +BGL5.1ECGSinus Tach12 LeadSinus Tach Modifiers If patient is not transported in a semi sitting position, move to state 3If Nitro is not repeated and CPAP not titrated move to state 3Trigger End of Scenario (12 Minutes) Patient State 3: State: Severe DistressTRIGGER: No treatment/change, not appropriate transportVital Signs Expected ActionsHR190Insertion of an oropharyngeal airwayProper ventilation techniqueMedication is discontinuedEpinephrine is administered accoriding to local protocols (0.5mg IM)SPO264%BP180/130RR64CO215Temp36.6SkinDiaphGCSE4,V2,M5Pupils+ +BGL5.1ECGTachy w/ PVC12 LeadTachy w/PVCModifiers If Nitro/CPAP are started or titrated if already started move to stage 2If patient is returned to the semi sitting position return to stage 2Trigger End of Scenario (12 minutes ) ................
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