Register now to gain access to all of our features. Once registered and logged in, you will be able to create topics, post replies to existing topics, give reputation to other members, get your own private messenger, post status updates, manage your profile and so much more. This message will be removed once you have signed in.
It would be quite embarrassing to come into the ER with the blood glucose still so low. Do we have a reason why she became hypoglycemic? She doesn't have a history of DM, Is this just some physiologic stress coupled with beta-blockade and some low glycogen stores?
Do you know if there's a name for neurological deficit in the setting of hypoglycemia? I've seen this a lot -- usually it's obvious that they're hypoglycemic because you see a lot of sympathetic response (in this situation elderly + beta-blockade this is blunted).
While I would kill my own dead grandmother for a free cup of coffee on any given day (actually, I'm pretty sure she'd kick my ass), I'm not sure what's more concerning, the fact that the ER would provide free coffee to incentivise transport to their site, or that EMS providers would bypass an ER just because it didn't have free coffee. Mostly I feel jealousy. My ERs have a free mop bucket, with complimentary scum.
http://www.ncbi.nlm.nih.gov/pubmed/21879897 [Link to free .pdf on page]
N Engl J Med. 2011 Sep 1;365(9):798-806. doi: 10.1056/NEJMoa1010821.
A trial of an impedance threshold device in out-of-hospital cardiac arrest.
Aufderheide TP1, Nichol G, Rea TD, Brown SP, Leroux BG, Pepe PE, Kudenchuk PJ, Christenson J, Daya MR, Dorian P, Callaway CW, Idris AH, Andrusiek D, Stephens SW, Hostler D, Davis DP, Dunford JV, Pirrallo RG, Stiell IG, Clement CM, Craig A, Van Ottingham L, Schmidt TA, Wang HE, Weisfeldt ML, Ornato JP, Sopko G; Resuscitation Outcomes Consortium (ROC) Investigators.
The impedance threshold device (ITD) is designed to enhance venous return and cardiac output during cardiopulmonary resuscitation (CPR) by increasing the degree of negative intrathoracic pressure. Previous studies have suggested that the use of an ITD during CPR may improve survival rates after cardiac arrest.
We compared the use of an active ITD with that of a sham ITD in patients with out-of-hospital cardiac arrest who underwent standard CPR at 10 sites in the United States and Canada. Patients, investigators, study coordinators, and all care providers were unaware of the treatment assignments. The primary outcome was survival to hospital discharge with satisfactory function (i.e., a score of ≤3 on the modified Rankin scale, which ranges from 0 to 6, with higher scores indicating greater disability).
Of 8718 patients included in the analysis, 4345 were randomly assigned to treatment with a sham ITD and 4373 to treatment with an active device. A total of 260 patients (6.0%) in the sham-ITD group and 254 patients (5.8%) in the active-ITD group met the primary outcome (risk difference adjusted for sequential monitoring, -0.1 percentage points; 95% confidence interval, -1.1 to 0.8; P=0.71). There were also no significant differences in the secondary outcomes, including rates of return of spontaneous circulation on arrival at the emergency department, survival to hospital admission, and survival to hospital discharge.
Use of the ITD did not significantly improve survival with satisfactory function among patients with out-of-hospital cardiac arrest receiving standard CPR. (Funded by the National Heart, Lung, and Blood Institute and others; ROC PRIMED ClinicalTrials.gov number, NCT00394706.).
When I look at my peers who have developed PTSD, it's hard to discount their experiences and say, "This couldn't have been me". I think we all have our breaking point. I think that our abilities to cope with the traumatic events we experience are often related to how well our personal lives are. It's easier for me to deal with difficult calls when things are good at home. When they're not, I'm simply more vulnerable.
It's easy to judge someone else for having PTSD. If you judge that individual, you don't have to accept that that could have been you. These attitudes prevent us from seeking help, and prevent our peers from seeking help, and ultimately they probably contribute to the suicides that happen. It's a terrible thing to sit back afterwards and wonder, what could we have done to prevent this?
Sorry, 23 mg/dl (US units - hypoglycemic) or 23 mmol/L (International units - hyperglycemic)? If she is hypoglycemic, we should give 12.5 g of dextrose and reassess (a lower dose, d/t the association with badness in neurological injury, and likeliness of intracranial ungoodness). . If she is hypoglycemic, this might explain the right-sided neuro deficits (is there a fancy medical name for this? I know Todd's paresis is focal deficit following seizure? I like to advertise this as much as possible so that I can pretend to be more intelligent than i am).
We've got the description earlier that her airway is "patent", even though she's obtunded (GCS 10). Can we get a saturation on her? I assume she's moving good air, and her lungs sounds are ok? No right lower lobe aspiration crackles? The previously fractured pelvis is not obviously fractured again on physical exam? (I appreciate it's a ramus, so it may be difficult to tell). I think from the information I have, I'd be comfortable holding off on advanced airway management, especially if we're going to the community ED 5 minutes away (which in all likelihood would be a good plan if we were going to meet a helicopter or for stabilisation prior to driving 45 minutes).
If an emergency medicine staffed ER is willing to take this patient, then I think I'm willing to defer to their greater experience, education and judgment.
It would be nice to have a blood pressure.
Regarding the ECG, the description we were given is "sinus rhythm". So, the 12-lead shows NSR as well?
I'm lucky this isn't an issue locally (non-US). The only health economics issue I remember running into is when we first started thrombolysing people, we were run municipally, and the city was losing a couple of thousand dollars on every eligible STEMI for the cost of the tenecteplase. Ultimately the hospitals starting supplying us for free. Now we've changed governance models, and this is no longer an issue.
With public medicine though, comes a sort of chronic under-funding and under-staffing. So it's not always a win.
Well, it's beginning to sound like maybe she should have got a CT last night.
It sounds like the family has a pretty good explanation for the fall, it's probably a simple trip and fall. This may be partly a result of all the infirmities of age, a prior ortho' injury, and possibly a bit of Parkinson's developing ("shuffling gate"). I think for confounders, any suspicion of elder abuse? Any recent med changes? Any suspicion of sepsis? While we may have other more pressing issues to deal with, it would be nice to point out to the ER if there are any issues in the home to be aware of, e.g. other trip hazards, need for handrails, walking aids, home care, etc. This is beginning to have the smell of a one-way trip.
Unfortunately, I think even with this good history, we have to c-spine her. If she was 40 years old with this history I wouldn't. This is going to increase her ICP, decrease her respiratory reserve, increase her risk of aspiration, and make intubation more difficult. But, I can't see the ER being too happy if I don't.
ITLS would make this a critical trauma, and we'd be tearing out of there like it's the end of the world. Reality, this has developed over night. Let's get an IV, bG and a set of vitals, and run a 3-lead, and make a decision about where we're going. The 12-lead can probably get done during transport, or as it takes all of two minutes, on scene. I'd pull some blood for an iSTAT en route. It seems unlikely that she's hypoglycemic (although she is old and beta-blocked, which could mask some symptomology) or that this is some sort of atypical seizure activity, but those possibilities should be respected.
It's tough here. She's old, probably has a subdural, but may not, probably isn't a good neurosurgical candidate, and has been sympomatic for an unknown period of time. Palliation is a likely pathway. However, it's not really appropriate to speculate on that until a physician has reviewed a CT. On one hand, the local ED with a CT can do this, ease some burden on the trauma center, and rule out some ddx. On the other, if she does have a significant subdural, we're just wasting time, waiting for secondary transfer.
In an ideal world, I'd call a physican, respect that they have greater knowledge of this area, and ask their preference. This also avoids me having to take responsibility for a decision where there's good reasons to go both ways. Forced to make the decision myself, I would lean towards transporting to the trauma center.
* This person is very old. Do they have any documentation limiting what care we can provide?
* That looks like a hematoma, not a clear depressed skull fracture.
* I like that my fire department uses words like "depressed skull fracture", and am impressed that they're not hitting on the patient's granddaughter.
(1) I would like more information about the patient's history, and events surrounding the injury, e.g. fall vs syncope, prodrome, seizure-like activiity, pacemaker / AICD,. anticoagulation (riding the old dagatrabin train?), etc. Are there any bystanders, or obvious findings on scene?
(2) ABCDE -- Are they moving all four limbs (particularly the ride side), is there a hx of ambulation since the injury? Aniscoria? We may have to c-spine this person if our history is limited/unreliable and they're comatose. I really don't want to have to do this, especially in an octagenarian I may have to intubate.
(3) I have to ask, is it really a depressed skull fracture? Do they smell toast when I push down on it? We should probably avoid the "depressed-skull-fracture by committee" where six different providers push down on the same swollen mass and eventually decide there is a solid structure underneath that seems to be moving.
(4) I guess we should do an H&P?
(5) I'm not up on what makes a level 3 trauma center. Is this EM stafffed? Does it have a CT scanner? Presumably no neurosurg / neuroICU?
[Edit: needed a question mark, probably a couple more beer. And had questions about trauma center designations]
I think this depends a bit on what sort of facility you're transporting to. If I'm 10 minutes from a trauma center, they'll only get intubated if they have no gag or I can't keep their sats > 90%, and they'll end up with an IV or IO. If I'm 10 minutes from a rural ER without EM coverage, I'm probably just going to stop and RSI them now, and either bypass to a bigger ER, or call for a helicopter.
I'm not great at reading labs, but his CO2 is 20, so his HCO3- is probably around 18 mM, right? So, is the metabolic acidosis here just lactic acidosis? Also, why the hypokalemia / hyponatermia? Is there some SIADH here too? On one hand, his crit's 48, but his calculated osmolarity looks to be around 275?
Just wondering. I'm trying to get better with this sort of thing since I got access to an iSTAT and started working in the ER a little on the side.
The problem with these case presentations, is we each imagine a slightly different patient. I look at this and see someone hypertensive, with some mildly concerning symptoms; headache, dizziness, proteinuria, and you see the beginnings of hypertensive encephalopathy. We may both be right, but we're just visualising different patients. It's really hard to talk in hypotheticals.
I think the analgesia for the headache is a little problematic here, and the best agent probably depends on the severity of the pain. If it is severe and debilitating, some morphine might be a reasonable choice, but runs the risk of obscuring the initial neuro exam, complicating and worsening any change in level of consciousness, and causing a rebound effect. Most headache situations I tend to opt for toradol, but with this hypertension, and the ACE inhibitor, there's got to be some concern about renal function, which means toradol probably isn't the best choice either. I think if you're going to treat, small aliquots of morphine might be the best.
If we were to attempt to reduce MAP, labetalol seems like a good option, as you've got some alpha effects there too. I think there's got to be some respect for the history of reactive airway disease in this patient if we're going to give a better blocker, though. In years gone by, we gave nicardipine (adalat), but created some spectacular messes, as it tended to be a little unpredictable. I'm not sure what the best practice is here (hopefully ERDoc can educate us), but based on what I have available on my ambulance, if we treated, I'd expect to get orders for some IV nitroglycerin, maybe with some metoprolol to block any reflex tachycardia.
So, based on the initial description, I wouldn't treat this. Yes, she's hypertensive, and she has a headache and some dizziness, which could be the beginning of a CVA.
That being said, she doesn't have any altered mental status, any focal neuro deficitis, any slurred speech, photophobia, nuchal rigidity, ataxia, vertigo, etc. Even if she is having a CVA, this may be the MAP she needs to autoregulate. If, and it's a big if, she's having a CVA, then our target MAP is going to be different based on etiology.
I would sit on the patient, reassess, and let the ER work her up.
The largest employer in my region has moved to this design, for all operations; urban / suburban / rural / ALS / BLS / IFT.
We are told they are safer, which they probably are, if staff wear the seatbelt as much as possible. Personally, I'm still not convinced that they're much safer --- most ambulance models haven't been crash-tested, and many have hard corners on the cabinetry that are essentially plywood edges covered with a quarter-inch of foam. On the other hand, any move in the direction of safety is long overdue. I fear the bench seat is an endangered species, and will soon be extinct.
In terms of negatives, on the models we use, it's impossible to turn the seat 90 degrees to the patient, because your knees/shins will contact the stretcher. In the trucks that do primarily IFT / LDTs, I see most of the seats rotated forward in the direction of travel. In most of the trucks doing 911, I see it facing 45 degrees towards the patient, which is a compromise to allow for patient care while preserving some leg room. On the models I've used, it's not desirable or particularly easy to move the seat while providing patient care. It seems like some of the handles for seat adjustment tend to break off. The positioning of the seat tends to restrict access to the patient somewhat, and make for some awkward IV starts.
Removing the bench seat also results in a loss of storage space, causing some supplies to be moved to external cupboards. One of the compromises, in the models I've used, is that the monitor is placed in front of attendants seat, which makes it pretty much impossible to position so that everyone in the truck can see it. It also leads to cables obstructing movement from the seat.
So personally, I don't like these designs. I think they take up too much space, are not that usable, but will probably improve. A fair bit of this is not liking change, and may be specific to the implementation my employer has adopted, which didn't have a lot of consultation with front-line staff. My preference is for a bench seat configuration, but, I think these are going to become rarer and eventually vanish.
So, as I understand the concept, it's not about removing the LSB completely. They still remain in use for intubated patients, combative patients, and those you can't communicate with. The idea, is that conscious, cooperative people will splint their own necks. Further, the application of a traditional LSB/blocks/collar restriction carries some real risks for the patient, with little or no proven benefit.
* It takes relatively little time on an LSB to cause pressure ulceration. Most trauma patients are already at increased risk.
* Traditional spinal restriction results in a 20% decrease in FRC, which could become a trigger for pre-hospital RSI.
* Spinal immobilisation can complicate airway management, and increases ICP.
* The LSB is a relatively poor device for spinal "immobiilisation", as you're trying to force a curved structure to conform to a rigid plane.
* Healthy volunteers often develop neck pain, and report moderate-to-severe pain when immobilised on an LSB, which can result in unnecessary imaging, which carries costs and risks to the patient.
I think the rolls/blocks are primarily there to remind the patient not to move their head. Which is pretty much what they do on an LSB, anyway. I think we're all aware that a patient can generate substantial joint motion while immobilised.
There's also the question as to how great the benefit really is with traditional techniques. Only a very small percentage of patients that are immobilised by EMS have c-spine fractures. The vast majority of these are stable fractures. Even most of the radiographicaly "unstable" fractures are not grossly unstable, as in the patient will move their head and displace their c-spine. They're unstable in the sense that it would be unwise to discharge them home, to play soccer or football without addressing the injury. Even when injury does occur in a patient that presents neurologically intact, it's difficult to know whether this is from motion during their care or the natural progression of the initial insult, e.g. cord contusion/concussion. There's a certain argument that the force required to fracture the c-spine is many magnitudes of order greater than any force the patient may apply through voluntary movement of their neck.
Also, consider the care provided in the ER, where often the patient is removed from the LSB prior to radiography, and left supine with instruction not to move their head. Even after an injury is identified, it's not like the patient is immediately put back on an LSB and then halo'd. They're basically put on a soft stretcher, and told not to move their head, and log rolled by staff. That's all this really Is. It may be a change in care for EMS, but it's not really a divergence from standard care in the ER.
The patients that are combative are still on the LSB --- and these are the patients the ER typically leaves on, right? Because we're using it as a restraint device as much as anything else. The patients that are intubated are still on the LSB -- they can't splint, and tube displacement is a potential disaster. The patients that are significantly altered, or who can't follow instructions due to a cognitive issue or language barrier, they're still on the LSB too. But what's happening, is there's a recognition of the limitations of the LSB, and that "immobilisation", is a fantasy -- what we're doing is restricted motion. This can be accomplished in a number of different ways, which can be tailored to the patient.