EMT City: mobey - Viewing Profile - EMT City

From a recent call.

66 y/o with a "benign tremor" of the upper limbs he has had since childhood.

Pt was c/o chest pain, pale, cool, dry.

You can barely identify a rhythm with the leads placed on the chest.... Now they must be moved to limbs for a 12 lead.

Do you sedate? or an Antiparkinson such as Cogentin?

Benzo's?
Forgo the ECG and treat symptoms?

The purpose of this question is to get a feel for standard of care.... I do not have one for these patients.

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My service is going ALS in 3 months (yaaaaay).
So it has been bestowed upon me to come up with a wish list of ALS equipment, since I have only interacted/worked for about 3 ALS systems I am looking for imput on what you guys like. Here is some background.

We have a low call volume of about 500/yr. We are 3.5hrs from a major hospital.
We do ALOT of peds calls.
We are "spoiled" in some peoples eyes..... electric cots, new chevy ambulances, stryker stair chairs, DVD players in the back of the rigs, etc etc. Money is an issue...... but for the most part, we want the best (within reason).

So I am looking for imput on any and all ALS equipment.
I'll get you started.... including, but not limited to

Transport ventilator? (No the genesis is not good enough)
Laryngoscope set? Plastic vs metal
Difficult intubation assistance (lighted stylette etc etc)
Commercial Cric kits?
IO kit? (BIG, EZIO, FAST?)

We already have LP 12's, and a 15 on the way, so monitors are taken care of.


Thx Mobey

I will do this in a call-review style (Grand rounds) cause I am not going to be available for alot of Q&A.

O/A Female 61 y/o patient found semi fowlers in elec bed. Pt in obvious resp distress. No response to verbal. Groans/localizes deep sternal rub. Cyanotic @ lips hands/feet. RR 22 deep, laboured. Snoring/gurgling audible. Vomit dried on sheets and Pt's face. Fresh Vomit on nightgown.
Well kept house in rural adress. 20min from major hospital.

PmHx: Husband states asthma - well controlled w/Spiriva. Pt recived "Transfusion" yesterday, but does not know what. Husband sts "She has no immune system".
That is all that's offered.

HxCc: Pt went to bed w/mild SOB & chest tightness. Husband awoke this AM to find her like this.

Vitals: BP 92/50 HR 134 sinus rythm, No St changes narrow QRS. BGL 6.2 Temp 38.7C. Pupils ERL @3mm.

Meds unknown (can't find them.) Husband sts, just asthma inhaler, pain med for arthritis, and a stomach pill for indegestion.

Exam findings: Pt obeise. UnCx. Responce to pain only. A/E = coarse crackles throughout all lung fields, bases sound more like rhonchi, not much air movement down there. Other than that, no real physical exam findings.

Tx: (Simplified) I.V. attempt X3 failed. I.O. established R tibia infusing NaCl. Intubate using 250mcg Fentanyl 7.0 tube. Redose w/ Fentanyl prn.

Vitals post intubation: HR 110 reg. BP 88/- Radials palpable. RR20 (pt still breathing on own) Temp 38.8C

So..... How do we correct the BP, the choices are
Fluid
Dopamine
Epi infusion


Remember 2 key things.
There is NO IV access. Only 1 I.O. (but we do have another IO needle if you like)
See Resp A/E sounds

SpO2 is a great tool when one knows the limitations. That has been discussed greatly on these boards.

I am wondering if anyone uses capnography waveforms and EtCO2 values when treating exacurbations of such conditions as Asthma, CHF, Emphasema, etc....

I am not talking about intubated pt's here.... I mean the nasal cannula style detectors.



Please withold the statements about treating the Pt not the monitor, and whether I am able to assess without a machine.