jwraider

Yep only thing that gors back in.

This would be my guess why that line of thinking works: Treating with benzos slows the high use of sugar and you are technically treating sugar levels by doing that (and setting yourself up for better IV access / Dextrose admin). Like controlling bleeding versus replacing blood. Same basic goal but 2 different parts of solving the problem.

So any thoughts on trying to use an NPA and an IN medication on the same patient? I'm trying to look up how to manage it but not having much luck. It's only a question for me because I think both are great potential treatments for a seizure patient but they seem to get in each others way. I was taught and still believe that the fundamentals of providing good 02 delivery (mandatory) and sugar (as needed) are very important.

So my county utilizes the IN route for Versed (seizures) and Narcan (narcotic OD). I'm wondering how you guys would handle the initial treatment of a status epilepticus patient with this administration route as an option? Let's say for example you walk onto a scene with a PT who is actively seizing and if you decide to gather a history that dictates you stop the seizure. The reason I'm posting this is I'm a newbie and I've probably had 20+ post-ictal patients but have never seen an active seizing individual. The closest I got was about 30 seconds after seizure activity stopped. My protocol works as follows if you would like to use it: -Maintain airway, respirations and provide 02 -Protect from injury and spinal immobilization as appropriate -Cooling measures as appropriate For status epilepticus: IV (lists that first I believe as a suggestion but not a reality) Midazolam 5 MG IN (2.5mg in each nostril) or 0.1 mg/kg IV/IM/ IO slowly in 2mg increments, titrate to seizure control Max single dose 6mg - Check blood glucose - Treat < 80 etc... This is what I would do/delegate please feel free to offer a differing opinion! Maintain manual cspine Apply a NRB @ 15lpm Apply a NC with capnography to monitor ventilations (nice tool we have) Skip the nasal airway Admin Versed 5mg IN as listed above Move to cspine as necessary Get a blood sugar/Get an IV (hopefully before they start kicking and fighting!) Place a nasal airway once I feel the Versed is absorbed Does anyone have a problem with delaying the nasal airway to admin the IN versed? That is what I am most worried about. Also any tips for what it's actually like to work with an actively seizing PT as far as airway as concerned? Thanks!

If I was running the perfect call (and I'm new too so I probably wouldn't have been) I would have gotten more info from the staff on her cardiac Hx and PNA Hx. Like what is her usual HR and rhythm? What has her temperature been? That is a pretty fast HR especially at her age. To answer your question I would have treated her if there was a long transport time and just did what you did if there was a short transport time. She did say her SOB got better with more 02 but either her HR or the gunk in her lungs is a problem and one probably should be addressed. As far as fluids go I think that HR is too high to say it's due to dehydration/sepsis along with her other S/S. Let's say shes real hot to the touch or the staff informs you she has a high temp maybe that changes things but then again thats more info from the staff that could answer your questions.

As far as the giggling... It's obviously just wrong but people react to death in many ways I've seen it happen before. Again not that it's right but most people haven't seen a dead body much less a fresh one with "CPR" being done (use that term lightly here). Maybe the arm chair quarterbacks could have jumped in and done better CPR instead of commenting on how poor it was (even though they are right).

I don't see how 2 people can effectively run a code for very long. They'd both have to be medics or no ALS would be getting done when the EMTs arms are jello and the medic does compressions. Not to mention effective compressions + ventilations should be two seperate (rotating?)people and again who's doing ALS? (chuck norris!) I don't think it's a valid excuse to bash fire. Whatever system you're in and however it's configured people need to figure out how to work together rather than continue that argument. Maybe I'll change my tune when I get more experience =)

Thanks everyone, I really appreciate all the help this board has provided I especially enjoyed the scenarios everyone participated in and helped me understand new ways of thinking. Happy Holidays! (ok "mom" 1 diet coke coming up!!)

Off to send in my application for a license =) It seems like the written test can be all over the board. My friend who took it at the same time mostly described BLS level questions and thought it was the easiest test he'd had to take in awhile. Mine seemed a bit tougher and every question I was not sure of I was able to clarify in my text book easily afterwards. My point being your text book is probably your best resource because the questions seem to be written based on exact content of the text book (I used a Mosby's).

When I had to clear and take off the MD was giving a beta blocker which I think means he doesn't know either and he was trying to protect the heart from possible ischmemia? The reason I posted this was to see how many would treat with lido and amio versus not doing that.

I recovered my PCR so I can answer this stuff better. Is the cough productive, if so, what color - Not productive When did the cough start - He just noticed it Does he have other symptoms that point you away from cardiac (one leg with pain instead of all over, fever, other flu symptoms) No but he did vomit 3x after waking this morning and denies BRB or coffee ground emesis. He had coffee to drink and that came up. The pain has been getting gradually worse nothing relieves it (constant) Is he on any pain meds now that he failed to mention or can not report on his medical record due to DOT rules. I can't go back and ask that but definetely possible. Sorry being an intern I didn't think of this until later but the allergies did trigger this line of thinking. What kind of ortho injuries and surgeries has he had - Sorry I dont know, he actually said ortho injuries, I did not see any scars on his chest Does he have any other PE symptoms - Well his lung sounds are good and he stopped complaining about the SOB after 02, RR 16 Does he have any left sided heart failure symptoms - Clear lung sounds, no edema, BP 140/90, Remember he has all-over general body pain -- rarely cardiac. - That was just my impression, he didn't vocalize that... He only complained of CP and SOB but the way he moved looked like someone who was in general discomfort and had general weakness. He did not want to move.

Yeah I'm kicking myself for not having the EKG but the one I did get with with some NSR in it did not show elevation and once in the ED they got a good one with elevation in V2 only (2mm). No T wave inversions, no major Q waves, no depression.

He denies any recent illness and goes into detail about how he drives a truck and he just finished a trip from Texas to California. He woke up with the pain this morning and you get the sense he might be somewhat stressed overall. He denies alcohol "I'm working" or substance abuse. 02, ASA, Nitro don't offer relief (I was at the ED fairly quick and didn't get an IV so I don't know what morphine would have done). He does move around like he is in extreme pain all over. When you eventually have him scoot from the gurney to the ED bed he acts like he can barely do it and grimaces. He did mention an extensive orthopedic history (either due to sports or work injuries I'm guessing) but I still think this behavior is due to his current infliction. Remember the PT is perfusing so I'm not sure if pacing is the right idea. Pads should still go on (just like they did in the ED)

OK I'm going to speculate alot here please don't laugh if I'm way off.... =) I called it accelerated ideo ventricular on call and my preceptor sqaushed that and said I need to consider it a V-tach (he says because it was faster than a normal ventricular rhythm or 20-40). I brought up the implications of knocking out an escape pacemaker if the Sinus wouldnt be there to back it up and we really didn't come to a good conclusion on what to do. I ended up using diesel because he was GCS 15, stable BP and had a radial (and the best cardiac hospital in the area was very close by). So anyway I call it "accelerated ideo ventricular rhythm with runs of normal sinus rhythm" and I'm really interested to find out where you're going with this doc because I didn't feel comfortable labeling V-tach or treating it that way and I want to know what was actually going on (imagine if I had a long transport) I guess if I'm calling it ventricular I need to focus on what would cause the ventricles to do that. Since he does go in and out of NSR it seems like the ventricles are irritable or there is increased automaticity in them. Looking closer at the rhythm strip the ventricular rhythm is barely faster than the sinus rhythm but it is faster. So maybe the increase in intrathoracic pressure when the PT coughs provides a momentary vagal effects and the SA takes back over. Or if that is totally wrong and the increase in intrathoracic pressure increases flow of blood back to the heart. So maybe the cough is increasing blood flow to the heart meaning the heart does not have enough blood (02) to begin with. So I'm back to something mechanical like an MI / blockage of a coronary artery. Or maybe disease in the chest wall or pericardfial sac is compressing an artery. I don't think this is an acute issue in his lungs because the lung sounds were too good but maybe something chronic from asthma has led to pulmonary HTN?

Doc I came up with the following am I on the right track? Sinus bradycardia with or without increased automaticity myocardial ischemia (especially inferior wall) dig toxicity electrolyte imbalance hypoxemia av dissociation reperfusion therapy rheumatic fever leading to valve damage congenital heart disease I think the low 02 disorders are very possible here but why? Probably either due to an MI or maybe a combo of something he ingested and an infection? He looked fairly healthy, I know I said poor IV accss but he wasn't severly overweight (just your typical 40 yo). So I have to go with some kind ischemia d/t an MI or damage from an infection.

No edema anywhere. SOB relieved with 02. Breath sounds equal bilat. RR 16 But maybe I didn't get the final ED diagnosis. So my protocol says to treat "tachycardia" with amiodarone. But this HR is 84 bpm and Ventricular tachycardia is defined by the AHA as 100 bpm (my protocl doesn't specify). Would you treat with Lido or Amio and could you call this V-tach?

woke up with it 7 hours ago then drove 4 hours before calling 911 (he was driving from texas to california on a big rig) Substernal, no radiation dull 9/10 no relief, he was sitting and in semi fowlers I did not try and lay him down. constant He forgot to mention the Pericarditis to me when I asked him about his history (why bother?). I found out about it in the ED from soemone else. My guess is it was long enough to go he did not think of it when I asked about it.

Sorry don't have the 12 lead printout but it confirmed the rhythm and did not show elevation when in NSR although it was tough to get a good picture because coughing doesnt lend to a steady EKG. All of those interventions are what I did and he does not change or feel better. Hx: Asthma, Pericarditis, Orthopedic surgeries (long time ago) Meds: Albuterol, Asthma Allergies: Torodol, Ibruporfen

Hey guys, this is one of the last few calls on my internship and the treatment really made me think since it did not fit into the cookie cutter scenarios presented in school. Thanks for playing along and giving me your ideas I'm really interested to see how everyone handles this: Dispatched to a BART station (above ground public transportation train) about 1 mile from a Hospital with a cath lab. Apon arrival you look around at the crowd and it's hard to find your patient as the local fire ALS engine hasn't arrived yet. You finally settle on a 40 yo male who is sitting alone on a bench and he looks scared or even as if he's seen a ghost. "Hi sir whats your name?" "Bob" You notice his skin is pale warm and dry and that he has labored breathing and is staring into space. "Whats wrong Bob?" "It's hard to breath.................... and my chest ..........hurts" You listen to his lungs and they are clear bilat and he moves adequate amounts of air. You have your EMT start prepping 02 (I used both a NRB and a capnography rigged nasal cannula) and get the BP cuff while you put him on the monitor. The FD shows up to help. You get: BP 148/90 HR 84 RR 16 SP02 on RA 96% GCS15 (no allergies no viagra type meds) and below are 2 looks at his ECG: ECG 1 ECG 2 You notice the rhythm goes back to normal sinus rhythm whenever the patient coughs... This repeats itself without fail on command 4-5 times during the call. Otherwise he stays in the bad rhythm. So questions? What are your treatments?

Thanks everyone I learned alot from this experience and your advice. My best guess is cardiac with some other disease process (infection) like Doczilla is saying. Maybe even due to her thyroid disease I saw a patient last week who had had a cardiac tamponade as a result of thyroid disease (although thats supposed to be rare).

"Sure glad you guys didn't walk her to the ambulance." Local FD did that last week with a COPD'er diaphoretic and talking in 1 word sentances but thats another story. "Fluid intake and output? Temp? Skin Turgor?" There was about 1/2 liter of normal looking yellow urine in the foley bag. UTI could be possible she is on a med "macro" which could be macrobid.... My fault for not knowing that for sure I had someone else copy down the drug names and read them to me and don't remember the exact name. I don't know her fluid intake and turgor was normal. Didn't have a way to take a temp but her skin temp felt normal. "someone with chest discomfort with neuro symptoms is dissection" I got a BP in both arms but a few minutes apart. I was taught to look for a difference which could suggest a AAA etc... any idea if doing them more than a few minutes apart counts? BP was similair in both arms. So you guys are considering the MI, CVA and also a possible infection which I see there are some signs for thanks. This is what I did: I had the EMT go code2 to Kaiser knowing I could divert to the other facilty if I identified a STEMI (on scene 12 lead was negative). I decided that since the symptoms started 6 hours ago this wasn't a "hot stroke". I got an 18 in her left AC and continued to ask her questions which is when I established the order of symptoms and that she might of had this kind of CP before. I did not give her ASA because I could not rule out a head bleed. After much debate I gave her nitro because my understanding is you don't want to make ICP worse with nitro (cerebral blood vessels dilating) but I didn't see any signs (pupils PERL, pulse pressure normal... now I'm sure that's not enough but that's what I went on). The nitro had a positive effect and she felt better. She actually was able to smile for me and once in the ER bed she seemed slightly more alert. When I got to Kaiser I spent 5 minutes arguing with the nurse about the PTs Kaiser number and "why is she on a NRB I'm going to take it off"......... 3-4 mins later the PT is in bed complaining of shortness of breath with a RA sat of 88%. They put her on 2 whole liters and started listening finally. Nice to know about the SOB but would havebeen nice to give a report and get in bed first. So my impression is cardiac since the nitro helped and there was a SOB factor discovered. What do you guys think? Any tips? Thanks for the replies!!

Blood sugar 116 (sorry that was important) Her pupils are PERL at about 3mm and RR was at 18-20. She also said the symptoms started 6 hours ago and got progressively worse. She only talks when you ask her a question although she does moan and groan some. Her answers always take a few seconds to start and she speaks very softly and slowly. She could either be in alot of pain and very tired or maybe she is actually having a neurological event. All her answers are correct just not elaborate. For example in response to "where does it hurt?" she can say "chest" but if you asked for something more complex like "what medications are you on?" or "can you tell me what happened?" she just won't say anything. I don't know if her speach was slurred it was hard to tell... "Slow" is the best way I can describe it. Sorry I forgot something: She has a foley which I discovered en route and the urine is a mild yellow color. (I don't know why someone who can use a walker has a foley) Her daughter was making the case that her LOC was different but seemed to be reffering to energy level more than anything.

Hi guys, had this call yesterday! I'm on the last bit of my internship so it was great experience for me (sorry if not so exciting for you). I'm very interested to see how each of you would approach the situation and how you would treat the patient. I'll follow up with what I did. Dispatched for 94 yo female "possible heart attack" You arrive on scene in a very nice home and are taken upstairs by the homeowner. On the way up she states her mother called her an hour ago and she came home from work then dialed 911. You enter an upstairs bedroom where the local FD has already initiated care. You see a 94 yo slightly obese woman sitting in a chair with her head tilted slightly back wearing a NRB who appears very lethargic and is not purposefully moving. FD reports PT is actually AOx4 just slow to respond. She is complaining of chest pressure but they think it may be a stroke because her grips "are very weak and she can't smile". They also state she has a Hx of TIA's and are just finishing up her initial set of vitals. You approach the patient and find a strong radial pulse, breathing is around 18 a min and adequate (CBL or clear bilat). When you ask the PT her name her eyes are open but she doesn't track you and she responds after 3-4 seconds in a quiet voice with the correct answer which she also does for the rest of your AO questions. Her answers continue to be sluggish and it's almost as if she's having trouble speaking because the answers are short and muffled. You determine that her chest "hurts" and both arms "hurt" and she is "very tired". You also confirm the very weak grips and when you ask her to smile she just doesn't seem to do it. BP 150/90 HR 112 Sinus Tach on monitor.... RR 18 SP02 100% (on 02) The decision to move to the ambulance is made and a stair chair is used. On the way down you talk to the daughter again who explains that her mom is usually able to move around with a walker and is "very active mentally". She says she has a Hx of TIA's and "heart stuff" and you grab the bucket'o'meds: Morphine, Lorazepam, Celexa, Warfarin, Levothyroid, Zyprexia, Macro (thats all the FD wrote down and it wasnt in the bin), Coumadin, Nifedipine - No allergies (Daughter didn't mention anything about pysch issues on scene) Hx: HTN, valve disease, CHF, Pulmonary Embolus, TIA You get into the ambulance and while the EMT gets the 12 lead ready and a BP is being re-taken you do a physical. PT has circumoral pallor, edema in both ankles (chronic), skins is white/pale warm and dry, lung sounds are still clear and adequate. Pain is described as "pressure" and is mid sternum going to left arm. Nothing makes it better or worse (including palpation) and 1 to 10 = "alot". PT states 6 hours ago she began to feel weak. about 2-3 hours later she noticed the chest pressure then a headache. Everything is getting progressively worse. She denies any recent illness and says she's had this pain before but is unable to ellaborate. New vitals: BP 176/96 HR 98 Sinus Rhythm RR 18 SP02 100%. EKG: (sorry don't have a copy!) No STEMI,the QRS is crappy looking (lots of zigs and zags) but never over .10 in size. No T wave inversion or depression (some leads show elevation and depression of less than 1mm). So you are 12 mins from the Kaiser hospital she belongs to with another hospital that is a stroke center with a cath lab about 1/2 mile away from the Kaiser hospital. I didn't find anything else out during the call and had to make my decision on where to transport and whether to treat her for chest pain or for a CVA. I was aware of the possible contraindications for ASA and nitro in a CVA so I was having a hard time making a decision on what to do (also why she didn't get CP meds early in the call). So what would you do? I'll post what I did later! Thanks! Would appreciate any suggestions on how to handle this kind of call and deal with a potential MI vs a CVA. Feel free to ask for more info sorry but you're looking through an interns eyes =)

I re-read my second Link and thoguht I'd repost to make sure other students found some of this stuff I'm finding helpful: 1) At the bottom it's saying Adenosine tends to preferentially block the anterograde AV pathway and cause a retrograde pathway or a re-entry pathway to be used actually causing a arrhythmia. Am I right in assuming this is a definite possibility for someone who is in Sinus tach? 2) Adenosine has additive effects with Digoxin, calcium channel blockers and beta blockers. You'll notice some of the seevre case studies gone awry the patient already had verapamil and digoxin on board. 3) Bronchospasm is a very possible side effect so be considerate of the PTs respiratory status. If they are SOB due to respiratory disease (versus cardiac reasons) use care.

Thanks guys. That all makes sense that blocking the AV stops the ventricular response and let's you see what the atria is doing. Then you can treat appropriately. I guess what I'm getting at: what is the appropriate treatment once you know it's not a re-entry tachycardia? If it's Sinus Tach adenosine is doing nothing to fix the "problem" right? Because this is what I think he said he would do (treat a sinus tach with adenosine). It doesn't make sense to me because the underlying problem that is creating a sinus tachycardia isn't something Adenosine will address. Also thanks for the link I had no idea it had so many different effects on the body.