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About krumel

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    Skiing, sailing, computer and geek-stuff

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    Who knows...
  1. Glucose, What's your highest?

    1852 mg/dl according to the hospital..The guy basically was a "medical multi-system-problem...Including MI, hyperglycaemia, etc. etc... He arrested when put on the stretcher, four more times in the ED and was declared 3h later...
  2. Respirations

    Completly true..But it still gives you nothing without a lot of Hx and some guesses..... I know patient having a resp of 30 for 25 years...without issues that are anyhow relevant for emergency medicine most of those 25 years. On the other hand: If I (who has a normal RR of 6-8) would have a Resp of 30 something is reallllllly wrong...
  3. Respirations

    I acutally know similar articles but still disagree. Respiratory rate does give you an very limited view of the patients respiratory condition as it is directly linked to a parameter that is only very rarely measured in an non-intubated patient: The tidal volume. Only by the combination of both we have a -more or less- valid view of the -theoretic- oxygenation situation that -might- arrive in the patient. The RR can be measured by a trained monkey...The tidal volume is very often measured wrong or not at all.... The main problems with high -or low- respiratory rate is not the problem of the rate itself (although it of course contributes to the oxygen demand) but the oxygenation deficiency that is a result of it. We are meanwhile in a position to monitor this oxygen deficiency much closer and with much better tools than we did in when main study that "proved" a link between chance to arrest and RespRate was done (Fieselmann, 1993). In times were prehospital&ED BGA is becoming more and more of a standard -contrary to the wards- we should not trust a parameter that has a "unknown" variable in it....
  4. Respirations

    Most useless parameter in emergency medicine....
  5. Intubation in 2012

    I totally agree with Jake when it comes to the point of "paralysis does not compensate for undersedation". My old service did mandate 100 proven&sucessful intubations+25 per year(5 of them RSI, 5 of them Ped) for Paramedics to allow them to RSI. For "resus" intubation 50 Intubations+15 per year were the minimum. As most suisse services are hospital based or hospital "associated" it at least was easy to archieve this as during time off you were more than welcome to assist in the OR. My current service is quite new to ET (as to any invasive skills). Therefore there are basically no rules..But we don't do RSI...So...In the end...Well...The rates are somewhere I better tell none...
  6. Monitors

    Afaik its on its way for FDA approval...Last date was "end of 2012"... We will see..
  7. Monitors

    A side note at this point: I would still get the MD when I have to choose between the 15 and the MD... I would -by far- prefer- the MD to the Propaq. (But there are better units than the MD...Thats what I meant....And of course it depends very much on the scenario you use it...) Personally I utterly hate the LP15..And love the Corpuls 3...
  8. Monitors

    I had the propaq MD a few times in my old job.... Had it for trial for a week and the air-ambo-guys had it as a standard. Personally I did not like the design of the display and the user interface...It does not feel as "hard-rugged" as the old one...
  9. PE vs psychosis

    Hey Island, "traumatic" was meant in the psychological meaning... Sorry about this confusion. I think the team was midlead by the following factors: - The patient was not cyanotic nor had bad SpO2 or expanded jugs - The patient was mobile for days - The time-frame for a typical post-curretage PE is normally much shorter and of course the effect of a highly agitated patient sometimes has.
  10. PE vs psychosis

    Arctickat: Yes, in general yes...Where two different monitors-brands (LP12 vs. the new propaq) but in general yes. Initially absolutely no indication of a drug abuse (spouse statement that he had her under "observation" for 24h, packed her bags, considering the fact that the hotel is isolated, quite posh & more for a older customer range it seemed unlikely that she bought something on scene, especially as she had no money...and considering the fact that drugs are not that well known in that part of the world). Complete and comprehensive drug screening was done during post mortem.. But:One of the few points the board criticized was that the fast drug screening kit (would have been available) was not used, especially in the pre-arrest time.
  11. PE vs psychosis

    Hey guys, I finally got permission to release a case report of a quite interesting case my former service had. I really would be happy to hear some opinions on this one. DISCLAIMER: THIS IS NOT AN AUSTRLIAN CASE ALTHOUGH I USED AUSTRALIAN QUALIFICATION NAMES. I simply could not find better names for the real "non-english" qualification of the people involved. Caller Statement: Young female, breathing difficulties. An ALS Truck, staffed with one Intensive-Care-Paramedic(10 years total expierence, 5y as graduate paramedic, 1.5y as ICP) and one advanced-care paramedic/EMT(5y expierence, in traning for ICP-paramedic) is dispatched to a remote country hotel. The service operates a "clinical decision model" where only a few guidelines (for resus&trauma) are established, there are no mandatory protocols. The weather is 32° Celsius, no clouds, the next basic care hospital is 22 min away from the scene, the next trauma-center 45minutes. The travel time to the scene is 17 Minutes. On scene the team is awaited by hotel staff and brought to the third floor of the hotel where they find a approx 30 y/o female sitting on the ground of a hotel room with a normal skin color who is remarkably agitated and extremely hyperventilating. A verbal approach/ "talk-down" to the patient seems not possible, the patient reacts with increased agitation to that. Therefore getting a direct patient Hx is impossible. The accompanying spouse informs the team that the patient had a recent miscarriage with a highly traumatic curettage 10d ago, no further medical history, allergies or medication is not known. The spouse suspects a psychotic episode as the psychological situation of the patient was degrading during the last days. The attached pulsoximetry shows 98% SpO2 and a HR of 100, getting a BP is impossible due to the patients movements. The auscultation of the lungs shows no abnormal diagnosis. There is no evidence of a further neurological problem visible, the patient is moving all 4 limbs with similar force, is able to identify persons, the pupils react PERL, the speech appears normal and the patient is speaking complete sentences, although not being orientated to person, situation, location or time. There is no evidence for a intoxication, the spouse was with the patient for the last 24hours and packed the bags of the patient. After further attempts by the spouse and the team to establish verbal contact with the patient failed the decision is made to sedate the patient, as a working diagnosis a presumed psychotic episode following the miscarriage is used. One arm is fixated and a 18G placed on the forearm without any problems. After securing the IV access and confirming the placement 4mg of Diazepam are administered. After awaiting the onset the patient appears to be a bit less agitated but still confused. Now taking a BP (110/70mmHg) and establishing a 3 Lead ECG (no abnormal diagnosis beside mild sinus tachycardia) is possible. As the patient still appears to be too agitated to securely transport her another 2mg of Diazepam are administered. After the onset of this dose a first attempt to transport the patient is done but due to the confined spaces (extremely small staircase, transport only in the carry canvas) and the fact that the patient is still trying to jump of the carry canvas the attempt is cancelled another 2mg of Diazepam is administered. After the onset of this dose the patient is now sleepy but opening eyes to pain (GCS9), has intact protective reflexes and a SpO2 of 98% on room air, HR90, BP as above. Another auscultation still shows no abnormal diagnosis, the hyperventilation has decreased, the RR is normal. A short palpation shows no abnormalities beside a small haematoma on the elbow. The patient is now again put on a carry canvas and carried the flights down, with a stop after each flight to recheck the airway and breathing. On the ground floor the patient is brought into recovery position and the airway and breathing is checked again. The patient now has a SpO2 of 95%, takes 8-10 deep breaths per minute and is maintaining her own airway. Now the patient is brought into the ambulance and is there observed by the advanced care paramedic while the intensive care medic is trying to get further medical history from the spouse and inform the receiving hospital, observing the patient thru the open door. After a few moments the advanced care paramedic notes a change in the skin color of the patient and immediately asks the ICP to join again. The SpO2 is now degrading rapidly, to 80% at the moment. Now a bradyarrythmia is noted with a frequency of 40. The patient is now rolled on her back and ventilated with bag valve mask with is no problem at this stage but within 20 seconds the patient goes straight into asytole. CPR is started by the ICP from the "over the head" position to allow the ACP to attach defib patches and to call for air-ambulance backup. Directly after this the patient receives the first dose of adrenaline (1mg) IV thru the IV-Line placed before. While doing CPR within the first minute the ICP notes increasing ventilation pressure and tries to place an oropharyngeal airway (Guedel). After two further ventilations (by now the ACP has taken over compressions) light-red blood comes out of the OPA, a minimal airway trauma from the insertion of the OPA is suspected and the OPA is removed. By now a large amount of light red blood is noted and the airway is first cleared manually and then my electrical suction. Another 30 seconds later the ventilatory situation degrades again and another huge amount of bloody fluid has to be removed from the airway, the patient at this stage lost approx 400ml of fluid thru the airway. Now the patient is intubated conventionally with ongoing CPR and without any problems.(7.5 ETT). Deep endotracheal suction produces another 100ml of bloody fluid and (increasingly foam), the capnography still shows 35mmHg. The auscultation shows wet rales on all four quadrants. The SpO2 under compression gives a value of 88% back. After the second adrenaline the patient goes into ROSC with a slightly tachycardic sinus rhythm. A good peripheral pressure of 130 to 90 mmHg can be taken, the ventilation is continued and a PEEP of 5 is started. After another 20-30 seconds the patients starts breathing against the tube and to bite on the tube. After another 40 seconds the patient goes into bradycardia (HR of 30) for about 30 seconds, after that directly into asystole. CPR is resumed and another 1mg of adrenaline is given. The ventilation has to be stopped soon as the airway again is again soiled with a massive amount of foam and fluid, almost 1l of fluid are now taken out of the airway. After another 90 seconds the patient goes into ROSC again, the situation is similar to the previous ROSC. The attempt to battle to onset of the bradycardia with continuous adrenaline administration and atropine IV failed, the patient goes into asystole after a short time. Within the next 3 minutes of CPR another 2mg of adrenalines are given (2x1mg), the airway is cleared two times of smaller amount of foam/fluid and a exjug is placed. Following this the patient again goes into ROSC for another 60 seconds. After the onset of the bradycardia pacing is attempted and remains successful for about 1.5 minutes (with good peripheral pressures) before the reaction is degrading and even increased energy does not show any results. CPR is now continued again. At this stage during CPR the patient has good peripheral pulses with a SpO2 of 87% and a CO2 of 30mmHg. Within the next 4 minutes the air ambulance doctor takes over the lead. He increases the PEEP pressure to 15. Further adrenaline is given, the airway is again cleaned from smaller amounts of fluid a few times. To reduce the chance of equipment failure the monitor is changed to the monitor of the air ambulance as the good SpO2 and especially CO2 parameters appear not logical. A further "all body examination" is done with no results. A few smaller episode occur but after further 30 Minutes of resus the patient is declared dead on scene. As the dead is treated as suspicious the dead is investigated by the authorities. The coroner's report later on states that more than 50 small size pulmonary emboli where found in the patients lung with another huge embolus in the uterus. Further investigation of the treatment by the local control boards and the coroner where done but no obvious mistake can be found. The use of intra-arrest- lysis is discussed but two different coronial experts state that even if administered (lysis was not available at any stage) when arriving at scene the patient would have nil chance of survival.
  12. Viagra and nitro hypotension

    @chbare:You are totally right... I had a massiv logic bug when writing that.. My way of thinking was to use the quite selective contractility increase to "fight" the decreasing pressure in the vital organs. But.... After reading it again I can't believe I wrote that... I will blame the massive flu I currently have for that Thanks for the correction!
  13. Viagra and nitro hypotension

    Sorry, that is wrong. Plain wrong. 1. Regarding the hands free: For that a more advanced service has pressure infusors or infusion cuffs... (similar to the ones you use for an art line) 2. Regarding the benefit: Your "experiment" is only valid (if it is valid at all)if you test it against a zero resistance infusion target. Infusing inside a vascular system that has things like its own pressure, valves and a vascular-muscle tone is a hole different setting (not even considering things like Bernoulli/Venturi or the fact that the "smallest" point is not the giving set but the exit of the IV-Cath)... BTW: The flowrate of a 14G free flowing IV is somewhere around 300ml... I personally worked with an pressure device that brings in 1500ml within a minute thru one 14G....
  14. Viagra and nitro hypotension

    I only had one case where we had a similar situation. 66y/o, lied to us when asked about previous medication... Ended up with massive hypotension, HR of 40 and apnoea at one stage. Treatment basically was the same as yours: Fluid (1000ml Bolus, 500ml of that pressurized), initially some epi (0.1mg) as a bolus, then we switched over to noradrenaline via syringe driver (I'm aware that Dobutamin might have been the better choice..but our choice was quite limited. Epi/Nor/nothing ) with 14 µg/min. In regards of the fluid overload: The position of the cardiac-center of my old work region goes into the direction that they are not "as afraid of the overload than the dehydrated" patient...
  15. Backboarding policy change

    Nice memo and for sure a one very well thought of... Just an observers notice: Have of the world who were using Scoops&vacuum matresses (or just scoops) by now have turned over to spineboards because they are "the good thing from the states".... I wonder what will happen nexxt... the US-Paras during to vacuum matresses?