This week we have the great opportunity to speak with the Chair of the SMCC paramedic program, Eric Wellman.

Today we are talking about the Affective Domain. Which is only helpful if you understand the context right? Bloom's taxonomy is a theory on how to create a better learning environment and more involved students.

The Three Domains of Learning:

• Cognitive: mental skills (knowledge)

• Affective: growth in feelings or emotional areas (attitude or self)

• Psychomotor: manual or physical skills (skills)

Today we are focusing on the affective domain. As we mentioned, This has been introduced into the National Standard Curriculum. 

Thank you for Listening! Please give us a like on Facebook, and subscribe on Itunes or wherever you get your podcast!

Director, P. (n.d.). EMT-PARAMEDIC: NATIONAL STANDARD CURRICULUM. Retrieved from http://www.nhtsa.gov/people/injury/ems/EMT-P/disk_1%5B1%5D/Intro.pdf

Lyman, K. J. (2014). The Relationship of Affective Domains and Cognitive Performance in Paramedic Students. University of South Florida. Retrieved from http://scholarcommons.usf.edu/cgi/viewcontent.cgi?article=6455&context=etd

Thank you for tuning into the MaineCrit podcast and checking out the show notes!

First, Transporting a patient in cardiac arrest is NOT beneficial unless the receiving facility is prepared and equipped to continue the resuscitation by treating reversible causes that EMS cannot. This is for EMS and ED providers.

A 42 year old man awoke in the middle of the night with sudden, sharp chest pain and shortness of breath.  He had no previous cardiac history and appeared very fit.  His wife called 911.  EMS arrived to find their patient in severe extremis and poorly perfused. He progressed to PEA arrest and the crew performed high quality CPR immediately. Advanced airway Obtained IV access. Several rounds of epinephrine. They worked the code for 20 minutes per protocol but did not get ROSC in the field so they called it.

The patient had minor surgery within the last week...

The hospital was half a mile away...

1. Most patients who suffer an OHCA will not survive intact unless ROSC occurs in the field.
2. There are reversible causes that most EMS systems cannot treat but an Emergency Department can.
3. There will be a small subset of viable patients that may be saved if transported expeditiously.
4. It is possible to transport patients in cardiac arrest safely with manual CPR and, perhaps someday, mechanical chest compressions and ventilation will open up additional options for longer transports to tertiary hospitals.
5. We must give every patient a chance for a successful outcome if such a chance exists.  That is what Resuscitationist do!  We must not give up unless there is nothing else that can be done.

SMACC/Cliff Reid - When Should Resuscitation Stop

ED ECMO - Annie (May 2013), 60+ minutes of CPR

Dr. Smith's ECG Blog - 68 minutes with chest compressions, full recovery.

Continuous mechanical chest compression during in-hospital cardiopulmonary resuscitation of patients with pulseless electrical activity

Double Bolus Thrombolysis for Suspected Massive Pulmonary Embolism during Cardiac Arrest

A simplified and structured teaching tool for the evaluation and management of pulseless electrical activity.

#NIHEMS change.org petition.

SMACCForce - dedicated to John Hinds

from

Mark Wilson

on

Vimeo

.

Minh Le Cong @ketaminh

Scott Weingart @emcrit

Cliff Reid @cliffreid

Anand Swaminathan @EMSwami

Last Mile Health

SMACC

Michael Lauria, Paramedic and MS-1

 to interview flight paramedic and MS-1, Michael Lauria(@ResusPadawan)

Scott Weingart's interview with Michael on Mental toughness.

John Greenwood's post about GRIT on IteachEM.

"New Med Students Training as EMTs"

SMACC Gold lecture on what works in education. The answer is yes. The answer is also no.

(

PubMed

)

And finally, Dat library...

Just a small piece. 

Shock:  Inadequate perfusion at the cellular level.

“The rude unhinging of the machinery of life” ~

Samuel D. Gross

Adequate Perfusion requires:

1. The Pump (heart)
2. The Fluid (blood)
3. The Container (vasculature)
4. Air Exchange (oxygenation / ventilation)

The Pump

• Adequate Cardiac Output
• Stroke Volume X Heart Rate (4-8L/minute)
• Affected by Preload, Contractile Force, and Afterload

The Fluid

• Volume of blood must fill container

The Container

• Vasculature is properly sized
• Pre and post capillary sphincters at local level

Air Exchange

• O2 into lungs and circulation
• Elimination of CO2 and waste products

• REQUIRES:
• Adequate FiO2 and ventilation
• Diffusion across alveoli / capillary membrane
• Adequate number of RBCs
• Efficient offloading to target cells

Stages of Shock

• Compensated
• Decompensated
• Irreversible

Types of Shock

• Hypovolemic
• Cardiogenic
• Distributive
• Obstructive

Managing Shock

• Primary Survey / ABCs
• O2
• BVM
• C  spine
• Major bleeding
• Supine / Keep warm
• IV, monitor

Specific Treatments

• Fluid challenge
• Epi / Benadryl (anaphylaxis)
• Chest decompression (tension pneumothorax)
• Pericardiocentesis (cardiac tamponade)
• Dysrhythmias (ACLS)
• Pressors (fluids first)
• Narcan (opiod OD)

Take Home Points

1. Shock:  Inadequate perfusion at the cellular level.
2. If you think shock, your patient is already there.
3. Know and treat the root causes.
4. Set a target MAP.
5. Be aggressive!

~Chip Getchell