MOD II 2016 ECRN CEBehavioral Emergencies,

Bariatric Patients, VAD’s, and

Life VestPrepared by:Deborah Semenek RN, EMT-P

Mark Dzwonkiewicz FP-C, LI

Elizabeth Peaslee RN

IDPH Site Code: 107200E-1216

1

Objectives Upon successful completion of this module, the ECRN will be able to:

1. Examine the differences in behavioral health diagnoses.

2. Review how to interact, de-escalate and treat patients with psychiatric disease.

3. Examine differences in patient care approaches when caring for the bariatric patient.

4. Review the patient population utilizing a VAD to support heart function.

5. Review care and transportation issues related to the patient with a VAD.

6. Review and discuss the use and care of a patient with a Life Vest.

7. Actively participate in review of selected Region X SOP’s related to the topic presented.

8. Successfully complete the post quiz with a score of 80% or better.2

Behavioral Emergencies

• Behavior- a persons observable conduct and activity

• Behavioral Emergency- A situation in which the patient’s

behavior becomes unusual, bizarre, threatening and/or

dangerous that another person takes notice.

• Factors that may indicate behavioral emergency….

• Core life function disruption

• Eating, sleeping, etc.

• Threat to oneself or others

• Deviation from societal expectations or norms3

Pathophysiology

• Up to 20% of the population has a form of mental health problem

• Most are cared for in outpatient centers

• Common reason for EMS involvement is due to medication non-compliance

4

Causes of Behavioral

Emergencies

• Biological

• Results from disease process

• Tumors or infections

• Structural changes

• Abuse of drugs and alcohol

• Never assume a patient with AMS has a

psychological condition until all possible medical

conditions or substance abuses are ruled out. 5

Psychosocial

• Related to personality style, unresolved

conflicts, or crisis management methods

• Examples….

• Traumatic childhood event

• Development of peer pressure

• Dysfunctional family

• Lack of parental support

• Abusive parent(s) 6

Sociocultural

• Related to patients actions and interactions with

society

• Effect patient social space, social isolation or

otherwise impact patient socialization

• Relationships, support system, social habits,

social skills and values

• Caused by profound events

• Rape, assault, witness to victimization of

others, death of a loved one, acts of violence7

AMS SOP

Consider Etiology

(Diabetes, drug overdose,

Poisoning, stroke,

Alcohol related)

Adult Routine Medical Care

Immobilize C-spine as indicated

Obtain blood glucose and record

If <60 administer Dextrose 50% 50 mL IVP/IO

-or-

Glucagon 1 mg IM/IN8

AMS SOP cont.If patient no alert, decreased respiration or

suspected narcotic overdose

Narcan 2mg IN/IVP/IO every 5 minutes as needed to

max dose of 10mg

• Attempt to ID substance involved

• Bring any containers found to hospital, so long as

they aren’t a safety risk

• Consider restraints prior to administration of

Narcan9

Remember Etiology

A- Acidosis,

Alcohol

E- Epilepsey

I- Infection

O- Overdose

U- Uremia

T- Trauma,

Tumor

I- Insulin

P- Psychosis

S- Stroke

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At The Scene

• Scene safety and BSI

• Call law enforcement, if necessary

• Begin to establish rapport

• Determine and document if patient is a threat to

themselves or others

• Examine the environment for potential threats

• If suicidal, patient can not be left alone. At

least one EMS provider must remain with the

patient 11

Verbal De-escalation

• Attempt with all patients

• Should be first method to attempt to calm aggressive

patient

• Safest because it requires no physical contact

• Be honest and straight forward with a friendly tone

• Avoid direct eye contact or invading patient’s personal

space which may increase stress and anxiety

• Can diffuse a situation and prevent further escalation and

eliminate the need for physical restraints

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Restraints• Last resort

• Two types- hard and soft

• Suggested to have 5 people for safe application

• Make every attempt to avoid injury to patient

• Never transport patient in prone position

• Document:

• Reason for restraint, type and location of

restraint, time of restraints

• Assess distal SMV’s 13

Condiser Medical

Etiology

• Hypoxia

• Substance Abuse/Overdose

• Excited Delirium/Hyperthermia

• Neurologic Disease (CVA, Intracerebral Bleed, etc.)

• Metabolic Problems (Hypoglycemia)

• Continue routine medical care for adult or pediatric patient

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Medications Needed• Contact medical control for pediatric

patients

• In patient with severe anxiety or agitation:

• Versed 2mg IN

• May repeat every 2 minutes until desired

results to max of 10mg

• If additional medication needed:

• Valium 5 mg IVP over 2 minutes, may

repeat up to 10mg or Valium 10mg IM15

Petition

• Legal documentation to transport patient to the hospital from the scene with or without patient consent

• Assist keeping patient in hospital throughout evaluation

• Family members, police, EMS or bystanders can complete petition

• Petition does not guarantee a patient to be committed

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Behavioral Emergency

Notes

• All region X hospitals can accept any psych patient

• Transport all medication or substance bottles saftly with patient

• Remember mentally ill patients are more aware of their surroundings than they appear, so becarful what is said around them

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Cognitive Disorders

• Organic causes such as brain injury or

disease

• Caused by physical or chemical injuries

• Delirium

• Dementia

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Delirium

• Rapid onset of widespread disorganized thoughts

(hours or days)

• Symptoms:

• Inattention, memory impairment,

disorientation and general clouding of the mind

• Causes:

• Medical conditions, intoxication or withdrawal

• Confusion is a hallmark sign19

Dementia

• Develops over months and is usually irreversible

• Several possible medical etiology

• Alzheimer’s, vascular problems, AIDS, head

trauma, Parkinson’s and substance abuse

• Involves…

• Memory, cognitive, and pervasive impairments

• Be supportive

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Schizophrenia

• Effects estimated 1% of the U.S. population

• Hallmark sign is a significant change in behavior

and loss of contact with reality

• Symptoms:

• Hallucinations, delusions and depression

• Symptoms will cause social or occupational

dysfunction

• Usually diagnosed in early adulthood 21

Anxiety Disorders

• Characterized by dominating apprehension and

fear

• Affects approximately 2-4% of the population

• Uneasiness, discomfort, apprehension and

restlessness

• Panic disorder, phobia, and post-traumatic

stress syndrome

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Panic Attack• Recurrant, extreme periods of anxiety resulting in great

emotional distress

• Acute in nature and unprovoked

• Usually peaks in 10 minutes and dissipates in 1 hour

• May present cardiac or respiratory in nature, so EMS must rule

out both possibilities

• Symptoms:

• Palpitations, sweating, trembling, shortness of breath, chest

pain or discomfort, nausea, dizziness, loss of control, fear of

dying, numbness or tingling sensation and/or chills or hot

flashes

• Management:

• Supportive care

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Phobias

• A fear that becomes excessive and interferes with

functioning

• The fear is considered intense and irrational

• Exposure to fear will induce anxiety or panic

attack

• Manage patients by being supportive

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Post-Traumatic Stress• A reaction to an extreme, usually life-threatening

stressor

• Natural disaster, victimization (rape, etc.), and

emotionally taxing situations

• Will avoid similar situations

• Recurrent intrusive thoughts

• Depression

• Sleep disturbances

• Nightmares

• Manage patient with respect, empathy and support25

Mood Disorders

• Pervasive and sustained emotion that colors a

person’s perception of the world

• Depression

• Bipolar Disorder

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Depression• Profound sadness or feeling of melancholy

• Most prevalent psychiatric condition

• Major depressive disorder

• Depression that is prolonged or severe

• Symptoms:

• Depressed most of the day

• Decreased interest in pleasure

• Weight loss

• Insomnia or hypersomnia

• Lack of concentration

• Thoughts of death27

Bipolar Disorders• One or more manic episodes with or without subsequent or

alternating periods of depression

• Begins suddenly and escalates rapidly over a few days

• Develops in adolescence or early adulthood

• Symptoms:

• Increased self-esteem

• Less need for sleep

• More talking or pressure to keep talking

• Flight of ideas

• Distractibility

• Increased goal-directed activity

• Delusional thoughts

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Substance Disorders

• Substance abuse is a common disorder

• EMS should rule out as a possibility when a patient

is experiencing a psychiatric or behavioral

disorder

• May present as depressed, psychotic or delirious

• Serious condition

• Patients may present ill from addiction or

withdrawal from the substance

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Withdrawal from Alcohol

• Happens from abrupt discontinuation or after

prolonged use or from rapid fall in blood alcohol

level

• Symptoms can occur several hours after last drink

and can last up to 5-7 days

• Seizures can occur within the first 24-36 hours

after last drink

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Withdrawal Signs and

Symptoms• Tremors of the hands, tongue, and eyelids

• Nausea and vomiting

• General weakness

• Tachycardia

• Sweating

• Hypertension

• Orthostatic hypotension

• Anxiety, irritability or depressed mood

• Hallucinations

• Poor sleep31

Delirium Tremens

• Usually develop in second or third day of withdrawal

• Symptoms:

• Decreased level of consciousness

• Hallucinations

• Misinterpretation of events

• Seizures

• Significant mortality rates

• Treatment with benzodiazepines can help prevent against

seizures32

Excited Delirium• Can be caused by drug intoxication, psychotic illness or both

• Signs/Symptoms:

• Abnormal pain tolerance, tachycardia, sweating, agitation,

skin that feels hot, lack of tiring, unusual strength,

inappropriate clothing

• Difficult to diagnose

• Be aware of the patient who becomes suddenly tranquil after

frenzied activity because this is usually followed by cardiac

collapse and/or death

• Always evaluate if a patient must be restrained

• Allowing a patient to struggle against restraints increases risk of

death 33

Bariatric

Patient

• Most common reason

EMS is toned out is

for undifferentiated

abdominal pain

• Always assure scene

safety and BSI

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Assess Patient Airway• Assess for patency

• Morbidly obese patients have excessive skin and adipose tissue around their cheeks, lower jaw and thorax which can place extra pressure on the tongue and airway

• Increased oxygen consumption

• Increased carbon dioxide production

• Excess metabolic activity35

Assessing Breathing• Decreased lung capacity from decreased chest

wall compliance and increased abdominal cavity contents

• Makes bariatric patients at risk for hypoxemia and hypercarbia

• Gives patients less respiratory reserve

• Prepare for rapid decline

• Breath sounds may be difficult to hear due to increased amount of adipose tissue

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Ventilation Complications• If patient has no c-spine injury, place the patient supine and use

blankets to place under head, neck and shoulders to place in a “ramp

position”

• Utilize oral and nasal airways

• Don’t overestimate lung volume due to patient size

• When possible use two person technique with a jaw thrust for BVM

ventilation

• If intubation needed….

• Prepare for difficult attempt in patients with sleep apnea

• Sedatives given can completely occlude airway with tongue

• Use capnography for tube confirmation due to difficulty with

auscultation r/t to increased adipose tissue37

Ramp Position

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Assessing Circulation• Increased stress on the heart

• Increased cardiac output even at rest due to the need for

extra tissue profusion

• Increased basal heart rate

• ECG may be less reliable due to the distance of the

electrodes to the heart

• Increased prevalence of heart disease in a younger

demographic

• If the need for immobilization arises, use caution so the

collar is not so tight it restricts blood flow to the major

vessels in the neck 39

Obtaining History• Per normal protocol, as with any patient

• Signs and symptoms of complaint

• Allergies

• Medications

• Past medical history

• Prepare for increased number of medical

conditions

• DM, HTN, hyperlipidemia, increased vascular

disease, stroke, cardiac disease, CHF,

peripheral edema, and ulcerations of the skin 40

Bariatric Surgery• To include gastric bypass, Lap-Band and gastric

sleeve can result in early and late complications

• Early- within the first month s/p surgery

• Think DVT, PE, wound infection, sepsis or GI

bleed

• Late- after the first month s/p surgery

• Think strictures, hernia or hardware

complications

• Gastric bypass has increased incident of ulcers

• Lap-Band has increased hardware malfunctions41

Bariatric Surgery

Gastric Bypass Lap-Band

42

Abdominal Assessment

• Exam will be complicated by loss of

anatomical landmarks

• Palpation of deep structures will be

limited due to amount of adipose

tissue

• Increased adipose tissue also limits

Cullen’s and Grey Turnner’s signs43

VAD’s

Ventricular Assist Device

Treatment for advanced

heart failure

Surgical process to

implant

Assists heart function by

circulating the blood

A continuous flow pump

Increases patient energy

level44

Indications

• Patient in class 3 or 4 heart failure while at rest or in

cardiogenic shock

• Short term

• Patient on transplant list but very sick

• Long term

• Not a transplant candidate

• Bridge to Recovery

• Treating cardiogenic shock

• Unable to come off heart-lung machine s/p surgery45

Usual Demographics

35-65 years old

Multiple medical

problems

Death is primarily

from non-VAD related

causes

Without transplant

survival rate is about

4-5 years46

Living with the VAD

• May return to daily activities with few limitations

• Patients look normal and healthy

• They have increased energy

• No travel restrictions

• Must avoid contact sports and water activities

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Risks To Patient

• Bleeding

• All VAD patients are on prophylactic anticoagulants

which increase a patients risk for bleeding

• Infection

• Direct access portal-of-entry to heart

• Stroke

• Device malfunction

• Death

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VAD Function

Inflow portion

surgically connected

to apex of left

ventricle

Outflow portion

surgically connected

to ascending aorta

Right side of heart can

still function normally

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Components of VAD Surgically implanted in body

with communication to the outside of the body

Pump

Inside body and delivers blood to aorta

Take over the work of left ventricle

Driveline

Inside and outside of body

Communicates with the pump

Don’t cut or disconnect, pump will stop

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Components (con’t)• System Controller

• Outside of the body

• Computer that controls all functions of the VAD

• “Brain”

• Batteries

• Outside the body

• External power source

• Last 4-12 hours

• Can press battery button to determine the charge level

• AC/wall power

• NEVER remove both power sources at the same time51

Care of the Driveline

• A wire that exits the body

• High risk for infection

• Always stays covered with a sterile dressing

• Direct portal to the heart

• DO NOT remove the dressing

• DO NOT pull or tug on the driveline

• DO NOT disconnect from battery pack

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Back Up Equipment All patients have a travel

bag

This bag contains:

Extra system controller

Extra set of charged

batteries

AC/ wall plug

Cell phone with appropriate

phone numbers

MUST come with the

patient for transport53

VAD Readings• Flow

• Amount of blood flowing through the pump

• Measured in L/min

• AKA cardiac output

• Speed

• A set number

• Shows how fast the pump is running

• PI

• Volume in left ventricle

• Power

• Amount of energy in WATTS to maintain speed54

Patient Assessment• Pulses may or may not be present

• Differs from patient to patient

• Use a stethoscope over lower part of heart to

listen for the “hmmm” sound of the VAD

working

• May only obtain blood pressure if patient has

pulses

• If no pulses, a Doppler is needed to assess

pressure

• Pulse-ox may be unreliable 55

Patient Assessment• Neurologic

• Increased risk for stroke due to anti-

coagulation

• Glucose levels are unaffected

• Skin parameters stay the same

• VAD doesn’t affect ECG

• Electrical activity continues in the heart with

or without capture

• PEA56

VADs & Anticoagulation

All VAD patients are

anticoagulated

Increased risk for bleeding

Take all bleeding

precautions

Coumadin/warfarin are

the only medication

approved for all devices

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EMS Arrest Interventions• Listen for the “hmmm” of the VAD, if you hear it, no need

for compressions. VAD is circulating the blood.

• If no “hmmm”, begin CPR

• Don’t worry about dislodging equipment because if

nothing is done patient has no survival chance

• Cardiac medications

• Can be given, but will have different levels of

effectiveness

• Discuss Dopamine with medical control prior to use

• 90-95% of patients have ICD’s, but if need arises EMS may

use their defibrillator

• Most arrests are not VAD failures, but rather some other

etiology

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Emergency Action

• VAD stops functioning, must be restored or patient

will die

• Check driveline connection to controller

• Check power lead connection to controller

• Check power source

• Replace system controller

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VAD Do’s and Don’tsDo

Follow CAB’s

Listen to family

Bring all VAD equipment

to the hospital

Keep patient on 2 good

power sources at all times

Do Not

Never disconnect

driveline from controller

Never disconnect both

power sources at the

same time

Never expose VAD to

water

Don’t open or view

sterile exit site

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EMS Tips

• Follow BLS protocol

• Make sure all connections are properly connected

• Verify power

• Listen to patient’s family

• Bring all equipment to hospital in the ambulance

• A DNR is not required for a VAD patient

61

Zoll Life

Vest

• First wearable

defibrillator

• 98% first shock efficacy

rate

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Zoll Life Vest

• Wearable defibrillator is a treatment option for sudden cardiac arrest

• Worn on the outside of the body

• Continuously monitors patient with dry non-adhesive electrodes

• If life-threatening rhythm is detected the device will alert patient prior to delivering shock to give the conscious patient a chance to turn the shock off

• If the patient is unconscious, the device will release a blue gel over the electrodes prior to delivering shock

63

Life Vest and EMS

• Standard evaluation and treatment

• Begin CPR if device is not saying

• “Press the response button”

• “Electric shock possible. Do not touch patient”

• “Bystanders do not interfere.”

• May replace with external defibrillator after removing Life Vest

• To remove

• First pull battery out

• Then remove vest

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Zoll Life Vest

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Case Scenario #1

A patient arrives via EMS with a chief complaint of feeling “under the weather”.

They are responsive, GCS 15, warm and dry, with a capillary refill less than 2

seconds. They have a VAD device.

How will the VAD influence the ability to complete the assessment of vital signs

and ECG for the patient?

Patient may or may not have pulses

No pulses means no blood pressure

The ECG will remain unaffected

66

Case Scenario #2

Your patient is suffering from severe anxiety.

What medications can be administered per CMC EMS Region X SOP’s?

Versed and Valium

What is the dosing parameters and route of administration of these medications?

Versed 2mg IN every 2 minutes, titrate to desired effect to a max dose of

10mg

Valium 5mg IVP over 2 minutes, repeat as needed to max dose of 10mg.

Valium 10mg IM

67

Case Scenario #3

EMS was toned out for a patient who, according to bystanders, “passed out”.

When they arrive they note a blue gel on the patient.

What does this indicate?

Patient is wearing a Life Vest

Your patient remains unconscious. What is the next step in assisting the patient?

If patient is safe to touch, take off Life Vest by removing battery first. Wipe

off blue gel from patient and apply EMS pads.

CPR and ACLS medications as needed.

68

Case Scenario #4

EMS arrives on scene for a morbidly obese patient complaining of difficulty

breathing.

How would their airway assessment change for this patient?

Breath sounds will be difficult to hear through extra adipose tissue

Excess tissue around cheeks, lower jaw and thorax decrease airway patency

Ventilation is more difficult

Intubation will be very difficult or impossible due to patient anatomy

69

Bibliography• Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practices, 4th

edition. Brady. 2013.

• Mistovich, J., Karren, K. Prehospital Emergency Care. 9th Edition. Brady. 2010.

• Page, B. Slap the Cap-The Role of Capnography in EMS. 2012.

• Region X SOP’s; IDPH Approved April 10, 2014.

• www.hearthope.com

• www.thoratec.com

• CMC EMS System CE Module August 2015

• Debbaudt, D. Autism Risk and Safety Management, 2011.

• Nixon, L. Universal Care of the Ventricular Assist Device (VAD) Patient,

powerpoint, 2015.

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