Skip to content
Paramedic Basics

Making paramedic care easier

Paramedic Basics

Making paramedic care easier

  • Home
  • Whiteboard Wednesday
  • About
  • Contact Us

Contact Us

Recent Posts

  • Cardio – Basic Anatomical Overview
  • CSI: Paramedic? Paramedic Roles in Preserving Crime Scenes and Evidence
  • Use Your Head! Treating Traumatic Head Injuries
  • Drive Like a Paramedic
  • Attending Major Incidents

@ParamedicBasics on Insta

  • #WhiteboardWednesday - Mental Health Assessment

Students and junior paramedics often feel that assessing patients with mental health issues can be challenging - a common fear is “saying the wrong thing”

Let’s be honest, we’ve all put our foot in our mouth on a job before. The key thing is to be humble and open to apologizing. Clear communication is essential.

Here is a breakdown of a standard mental status assessment, based off @ambulancevic CPGs. It includes some common findings you might identify in each category. Bear in mind that the goal isn’t to make a diagnosis - rather to gather useful information to guide your treatment and transport. 

Some tips for new players:
- Safety is always your number one priority. Although people with mental health issues are more likely to be the subject of violence (rather than the perpetrators), people in crisis can be unpredictable. Maintain a safe distance and assess for behaviors of concern before approaching

- Utilise all your de-escalation techniques. Control your voice and tone, use open body language, don’t stand over your patient and listen actively. Don’t rush to offer solutions, but when the time is right give appropriate options

- Remember that all patients are assumed to have decision making capacity, until it becomes obvious that they don’t. Your local laws will dictate who can receive mandatory mental health treatment, but remember that this doesn’t mean they can’t refuse other treatments. Take the time to explain things, build rapport and get informed consent

- Don’t be an arsehole… I don’t know how else to phrase this one. We are all humans, and people in mental health crisis are particularly vulnerable. They are NOT cornered animals, but sometimes they are desperate people. Keep that in mind, be respectful and don’t make false promises 

- Document a mental status assessment on each mental health case thoroughly 

At the bottom is some snippets from the new Mental Health and Well-being Act 2022 (Vic), which introduces new powers and responsibilities for paramedics, as part of statewide mental health reform

#paramedicbasics #mentalhealth #mentalhealthcrisis #assessment #paramedic #emt #ambulance
  • #WhiteboardWednesday - Bundle Branch Blocks

Something I really struggled with as a student, bundle branch blocks (BBBs) are commonly encountered by paramedics. Although they are usually not the primary problem we are called for, understanding BBBs and their causes can be incredibly helpful

BBBs occur when there is a disruption of either the left or right Bundle of His. This blocks the nerve impulse from travelling it’s usual path into the ventricle - instead the impulse has to travel across the cardiac muscle and septum, before reaching the opposite ventricle.

Due to this transmission through the myocardium, the depolarisation of the ventricles takes longer than normal. This results in a widened QRS complex (> 0.12s)

WHAT ABOUT LBBB AND STEMI?
You may notice that LBBBs present with ST-elevation - this is totally normal, based on the principle that a myocardium which depolarizes abnormally will also repolarise abnormally. But how can you tell if the patient is having a STEMI? Do yourself a favour and look up the Sgarbossa Criteria 😉

WHAT ABOUT TACHYCARDIC PATIENTS? ISN’T THAT VT?
Patients with a BBB has a wide QRS, so it can be very hard to differentiate a between SVT and VT in these patients. Generally speaking SVT with abberency will present with some level of haemodynamic stability and may have a known history of BBB. Conversely patients in VT will usually have no or low blood pressure. When in doubt, treat wide complex tachycardia as VT.

WHEN SHOULD I WORRY ABOUT A BBB?
New LBBB was previously considered to be a STEMI equivalent, however there isn’t good evidence for this. Also - how can we tell if the LBBB is new? Unless the patient had an ECG yesterday, we really can’t tell

However patients with cardiac chest pain and/or haemodynamic compromise, in the setting of a suspected new BBB, could be a sign of OMI

#paramedicbasics #ecg #paramedicstudent #cardiology #ecgbasics
  • #WhiteboardWednesday - Basic 12 Lead ECG Interpretation

12 Lead ECGs give us a more detailed, three dimensional view of the heart. It allows us to see the anterior, lateral and inferior parts of the heart. By changing dot placement, we can also see the right side and even posterior!

SYSTEMATIC INTERPRETATION:
- rate
- regularity
- P waves
- PR interval

- QRS complex
(Looking for widened QRS complexes with signs of Bundle Branch Block)

- ST segment
(Looking for *significant* ST elevation in 2 or more contiguous leads, or ST depression. Knowing your coronary artery anatomy will let you determine the culprit artery!)

- T waves

[check last week’s post to revise these!!]

- Axis deviation. I don’t get too technical about this - I describe it as the “general direction electricity is travelling through the heart”. It is measured as an angle, where 0 degrees follows Lead I (straight line from right arm to left arm). A normal axis is between -30 degrees to +90 degrees (that is, electricity is moving through the heart from top to bottom, roughly towards the left leg).

CALCULATING AXIS DEVIATION: Quadrant method
Look at the QRS complexes in Lead I and aVF. Assess whether they are mostly positive (upright) or negative (inverted).

Remember that a positive deflection on the ECG means electricity is traveling in that direction. So if Lead I is positive, electricity is traveling along the 0 degree axis.

Now apply the following rule:
Lead I +, aVF + = normal axis
Lead I +, aVF - = left axis
Lead I -, aVF + = right axis
Lead I -, aVF - = extreme right axis

LEFT AXIS DEVIATION CAUSES:
LBBB, left ventricular hypertrophy, WPW, inferior MI, ventricular pacing, short/squat stature (horizontally orientated heart)

RIGHT AXIS DEVIATION CAUSES:
RV hypertrophy, RV strain (such as in PE), chronic lung disease, hyperkalaemia, TCA toxicity, dextrocardia, vertically orientated heart (tall/skinny). Normal finding in paediatric ECGs as right ventricle is similar size to left after birth.

EXTREME RIGHT AXIS CAUSES:
VT, hyperkalaemia, severe RV hypertrophy

Had any interesting 12 leads lately? Let me know??

REF: @litflblog 

#paramedicbasics #ecg #ekg #12lead #paramedic #cardiology
  • #WhiteboardWednesday - Basic ECG/EKG Interpretation

The electrocardiogram is a wonderful device which measures the electrical activity of the heart and presents it as a bunch of squiggles on paper. Hence I often refer to it as a “picture of the heart” or “heart tracing” to my patients.

The ECG is one of the most important tools when investigating cardiac complaints. Here is a basic guide to interpretation

1. Make sure your dot placement is correct

2. Assess the rate. This can be achieved using the 6-second method (my preference) or the 300 method.

3. Assess regularity/rhythm. This is done by marking out complexes on a scrap bit of paper and moving it along.

4. Look at P waves. These represent atrial depolarization/contraction and give us an idea of what is going on inside the atria. Common abnormalities are fibrillatory waves, flutter waves or inverted P waves. P waves can also indicate atrial hypertrophy (P mitrale and P pulmonae)

5. Look at PR interval. This indicates the time taken for the electrical impulse to travel from the atria, through the AV node and to the venticles. The PR interval gives hints about problems with conduction through (or in abnormal cases, around) the AV node.

6. QRS Complex. This indicates ventricular depolarization/contraction, as the impulse travels down the intraventricular septum and through the Bundles of His. An impulse following this pathway will be narrow, whilst abnormal conduction will be wider (as it takes longer)

7. ST segment. Should be isoelectric, elevation can indicate ischaemia (more on this next week!)

8. T waves - indicate ventricular repolarisation. Normally upright and shorter than the QRS complex, abnormalities can indicate early ischaemia or electrolyte abnormalities

Working through the ECG systematically is the key to identifying the rhythm and what the anatomy is doing. ECGs bring together the electrical and mechanical function of the heart, and are a code just waiting to be cracked!

Want more info? Most of this comes from the awesome LITFL team! @litflblog 

#paramedicbasics #ecg #ekg #electrocardiogram #cardiology #paramedic #studentparamedic #nurse #medicine #doctor #education #studentnurse
  • #WhiteboardWednesday - Non-invasive ventilation (NIV)

We know that non-invasive ventilation is great for patients with respiratory distress - but what’s the difference between BPAP vs CPAP? IPAP vs EPAP? What do paramedics need to know?

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP):
- Provides a continuous flow of air and pressure, regardless of what the patient is doing
- This stents open the smaller airways and prevents the alveoli from collapsing. Keeping the alveoli open increases their ability to exchange gas
- CPAP is great for patients with Type 1 respiratory failure, such as acute pulmonary oedema or pneumonia
- CPAP only has one pressure setting, which can be referred to as CPAP / EPAP / PEEP

Bilevel Positive Airway Pressure (BPAP)
- Provides two levels of pressure, a higher one during inspiration and a lower one during expiration. This provides the benefit of assisting the patient during inspiration (reducing work of breathing) whilst also maintaining the airway/alveolar latency during expiration (without unnecessary added pressure)
- This adds the benefit of improved ventilation on top of the benefits of CPAP
- Therefore BPAP is great for patients with Type 2 respiratory failure, such as COPD or asthma 
- BPAP has two pressure settings - inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP). Some different brand devices will use different terms for these. Some may use pressure support instead of IPAP
- FiO2 can also be adjusted

KEYS TO SUCCESSFUL NIV:
- implement it early
- coach and reassure the patient constantly, as the mask can sound and feel very confronting
- optimize the patient’s condition with medication where indicated
- ensure the patient is positioned upright with adequate mask seal
- don’t forget to escalate care where necessary

#paramedicbasics #paramedic #ems #emt #niv #cpap #bipap #ventilation #emergency #nursing #medicine #respiratory
Follow Us!
© Paramedic Basics. All rights reserved. | Developed by: Avid Themes
Powered by WordPress