MSDeltaFlt

My pleasure.

So long as their VS can handle it.

As far as therapeutic levels go, you'll know you're getting therapeutic when VS, breath sounds, and overall pt status improve.

When you hear more air exchanging, respirations are less labored, and pt states they're breathing better, you're getting there. When lungs are clear, and there's no SOB, then you're therapeutic. Odds are you might not make it THAT far by the time you get to the hospital. Just get them on the road to recovery is all you can do most of the time.

It's redundant because of its length of duration. It will still be working at its peak 4hrs after you give it. That's why. So just give it once with albuterol and then you don't need to give it again until 4hrs later at the earliest; sometimes 6hrs later. However you CAN keep giving albuterol only back to back and even continuously for an hour or two to get the effect you need; so long as pt's VS will tolerate it (Heart Rate, BP, cardiac O2 demand, etc).

Atrovent any more frequent than Q4-6hrs is redundant. Give it once with albuterol and then keep giving albuterol continuously.

Okay, this i think is an interesting follow on from the ipratropium thread that's kicking around here. I think it will be interesting to see what peoples decision will be because i sure was racking my brain about it.

So.....

You travel to a small rural hospital for a routine transfer, 48 y/o M, going for a chest x-ray at a major hospital 40 minutes away. All your told is he will require 02... this is what you find when you get there......

Arrive 1200 hrs

HX of chronic asthma, ruptured discs c3-7 and L4 with severe 6/10 sciatica

Allergic to morphine, tranadol,

On fentanyl patchs 300mcg, temazepam, 25mg of prednisolone orally at 0800 and a whole lot of other shit, has been given IV fent by the hospital when needed Had an acute asthmatic episode at 0100 and has since had ventolin nebs 2/24 and nothing else.

Obs...

HR 80

B/P 130/100

SPO2 97% 3l/min via nasal cannula

no JVD

RR 34

full field wheezing left and right, diminished sound L base

Temp 37.6

speaking in single words

suprasternal retractions

profusely sweating

You start another ventolin/atrovent neb, whack in an IV and start you 40 minute trip. You cant position them upright because of the extreme pain the pt is in when you do so. There is some improvement in his respiratory state (speaking in phrases to sentences) all other obs the same - until his sciatica kicks in, at which point the pt is unable to speak, RR42, SATS drop to 90, B/P 1010/PALP, still full field wheezing and some JVD now - looks pre arrest, do you

A ) ditch the neb mask and give the only analgesic (inhaled analgesic)you have they are not allergic to to try and get on top of their pain as a method of controlling their SOB (you don't have IV fentynal, just morph)

B ) Airway takes priority, keep up with the nebuliser.

Intensive care truck is about 20 minutes away and has IV fent, dexamethesone etc etc

Think about it

it seems that most people are for treating the pain as a method of treating the SOB, is that right?

Chronic asthma and chronic pain in which he has acquired a tolerance of all kinds of things and is allergic to what you carry. In 40 mins you're not going to fix this guys pain. I doubt you'll even be able to take the edge off. Also pain is not mentioned in the primary survey. You are stuck on "B", my friend. Stick with the nebs. You'll be fine. So will the patient.

I wanted to discuss a topic that I am kind of struggling with.

Whether sedating a patient to intubate them, or maintaining sedation during a transfer/procedure, the standard round these parts is Fentanyl/Versed.

For simplicity I would like to keep the discussion within the limits of a average weight, normotensive, adult patient with no previous medical Hx, that needs sedated deep enough to maintain intubation for whatever reason.

So, like I said, most of my education/experience is about 5.0mg Midazolam, Start at (varies) 3mcg/kg Fentanyl then paralytics if needed, or more fentanyl in the absence of paralytics.

Continued sedation is usually 2.5mg doses of Versed, and 100mcg of Fentanyl.

My "struggle" is that being out here in the sticks I would rather have an infusion to maintain a steady state of sedation, than the highs and lows of redosing. Unfortunatly, the agents used in infusions are not-so common prehospitally in my area, and I am not sure why (although I did see a doc hang a Versed drip).

I am really interested in hearing some views on Propofol infusions and Ketamine, along with other agents.

Late in the game here. I apologize. I like the way CH thinks. He brings up some good points. Regardless of which meds you have at your disposal, there is something that needs to be made intimately aware of. There is a difference between "giving sedatives" and "sedating your patient". There is also a difference between "giving pain meds" and "treating pain". I, myself, was once on a Fentanyl drip in the ICU with an unstable C2 Fx and extubated myself. Thought I was dreaming. Apparently not.

Know the difference. Just my thoughts.

So far this year I'm 100% for ETI, however there were 2 pts where it took 2 attempts to get the tube.

Hello out there I'm wondering what tip/tricks you use to help setup 12 lead ecgs.

Like one of the tips i was taught for the limb leads is smoke over fire (black over red) snow over grass (white over green).

Thank you very much for any tips.

Generally speaking all of the electrode wires are color coded. They are also labeled. RA means Right Arm. LA means Left Arm and so on. Place them in the proper places and you'll get an accurate ECG.

http://library.med.utah.edu/kw/ecg/ecg_outline/Lesson1/lead_dia.html

V1: right 4th intercostal space

V2: left 4th intercostal space

V3: halfway between V2 and V4

V4: left 5th intercostal space, mid-clavicular line

V5: horizontal to V4, anterior axillary line

V6: horizontal to V5, mid-axillary line

Generally start placing V1 & V2, then V4, then V6. Then you place V3 between V2 and V4 and V5 between V4 and V6.

Question for all of you. ..... You have a pt c/o chest pain. pt denies sob and there is no evidence of an increased work of breathing. pt speaks in full sentences. My question is: if the pt is not in any obvious respiratory distress, do you wait to put the pt on oxygen until the 12 lead is finished. Why or why not?

Thanks.

It depends on the amount of chest pain and the kind of chest pain the pt complains of. Some pts' complaints of chest pain just as you described will get the full workup. Then again, some pts' complaints of chest pain just as you described will get absolutely nothing at all except maybe a trip to ED. It depends on what the assessment shows.

We were having a discussion in the chatroom about the techniques of intubating a patient. We have all been taught to hold the scope in our left hands, but could you hold it in your right hand and get the same effects as you do your left? I am running on Sunday or suspose to anyway so I am going to try it. Just wondering if you all have any thoughts on this.

Edited by me so I can clarify I wont be trying it on a live person....lol

Get a manikin and practice it that way, and imagine the way it'd look like on a real patient in a real scenario. that way you'll have a little better understanding of just how difficult it can be.

Some right handed people may try to tube with the blade in the right hand because they say they have more power and control with the blade in the right hand. If that's the case then they're doing it wrong. ETI is all technique; not power.

No NIBP will ever claim to be accurate. They are only good for one thing: trending. Get a baseline first by getting a manual.

When she climbed aboard a medevac helicopter in Charles County in September, emergency medical technician Tonya Mallard had no helmet, no flame-retardant flight suit and virtually no training. Hold the patient's hand and listen to the flight paramedic, a colleague told her over the roar of chopper blades.

To be honest with you, Vent. I absolutely do not understand that. In order to provide pt care on a helicopter, you have to go through so much training. But on a service with one medical crew member, that is not necessarily so. Some things just don't make sense to me.

Patients pulse was in the 160-180 range. Normal QRS. Had ST elevation with Reciprical ST depression.

So even if drug use, which patient denied, I should still assume MI based also on S/S's? I just know I have not found anything that says with cocaine expect to see these EKG changes.

Following MONA is indicated, as you well know, but street drug use can cause SVT. Granted they always deny, but the HR is high enough technically. What was the BP? What were the other S/S's?

Now we weren't there. Did your pt, according to your assessment, warrant Adenosine? Could it have been an option?

Personally I would make the drip a 1:1 concentration. Pull out 100cc from the bag to make it a 1:1. The size of the drip chamber is mute because Amio should be given by pump. I won't give it my gravity.

After reading the blog, I'd have to say that standard exposure protocols would probably not work. You'd have to take those protocols over the top and keep going. One would have to be very aggressive and very generous. Especially with pain management. 16,000,000 Scollville units, I believe, would more than likely hold the world's record. Anything you have to handle with tweezers and latex gloves should be considered a hazardous material.

Were there any adverse effects of only 200cc in? More than likely not.

I stand corrected.

Mostly I agree with what Arizona said. The Med Control was treating the symptoms moreso than the numbers. Plus you gotta think. Is a liter of fluid really that much fluid on an adult? He lost a liter and a half of blood in the truck. Blood is three times thicker than isotonic fluid. Running one bag in, MAYBE 2, is not unlike spitting in the ocean. It won't hurt him.

Were there any adverse effects of only 200cc in? More than likely not.

While writing this post I've been thinking. You ever wonder why MD's stand by the wall of the ER room when a pt is rolled in as they are giving orders? One reason is keep out of the way of us subordinates doing our work following their orders. The other is maybe they are taking in the "Big Picture" of what's going on.

Big picture here? Treat the symptoms. Run the bag in.

Humbly written

Isn't decreased lung sounds the criteria used to choose which side to decompress? It was explained to me that percussing helps decide whether it's a pneumo or hemopneumo.

But yes, I agree with at least being practiced with percussing during your training. If you end up working in an area with such short transports you hardly get to do it, you'll at least have the base knowledge in case you ever move systems or for some reasons have delayed transport.

That's just the thing. It helps. It's not all inclusive or exact, but it's still something you definitely need to learn.

What size was the tube? Small tubes and/or tight nasal passages = increased work of breathing which sets a pt up for failure or quick decompensation. Even a good sized tube has resistance that must be overcome and thus that is why we have all sorts of tube compensation modes on ICU ventilators.

Any amount of secretions can further block the tube either partially or completely and pt can quickly decompensate without one knowing in the back of a noisy truck and the pt covered by clothing or sheet. Dramatic SpO2 change may be late and after pH has fallen with the rise of PaCO2 especially if the patient is in a hyperoxygenated environment like a NRBM.

Was there an ETCO2 monitor in place? A pulse ox will tell nothing about the patients ability to clear CO2. Was the nare adequately prepped prior to intubation? Blood from the nasal intubation may also hampered effective gas exchange.

If the patient was obtunded they may already have had impaired gas exchange. The respiratory effort once the airway was open may have been an attempt to decrease a possibly high PaCO2 level that had already accumulated and increase their pH out of the danger zone.

Respiratory effort can be deceiving especially with impaired mental status.

It is rare that we intubate anybody for alcohol unless they are apneic or a child with a toxic level.

In the hospital, it is very rare to see a nasal intubation due to the high risk of infection and damage. If a patient is being weaned from a ventilator or post op, they may be on a T-Piece but the tube size is very adequate and ABGs give baseline while ETCO2 is monitored. Even that is rare due to safety issues and newer ventilatory modes on ICU ventilators to mimic a T-Piece which monitor the airway resistance with the appropriate alarms in place.

Many, many years ago in the hospital, we used to leave the tubes in comfort care patients when we discontinued life support until it was ruled cruel and uncomfortable care by our medical ethics committee.

Medic30,

Vent and I see eye to eye on a lot things. This is no different. I can understand why they nasally intubated. When you don't have RSI/DAI capabilities, you have to go nasal in order to better secure the airway sometimes. However, "Airway" and "Breathing" are not the same. In the same way "Oxygenation" (measured by SpO2%), "Respiration" (respiratory rate), and "Ventilation" (measured by EtCO2) are three completely different entities.

You can be breathing normally and oxygenating like a champ, but if you're not ventilating worth a damn, you're still gonna die. You've seen this happen. We've all seen this happen. If the CO2 gets too high, the pH will drop too low. Nothing will work in an acidic medium; up to and including pulses.

Did any adverse conditions actually happen? Probably not. But here's the thing. Luck counts, but don't count on luck.

Bag 'em. If they're still breathing, bag with them, but still bag 'em.

Advanced Practice Paramedics, I believe, should be able to bring critical care to EMS. RSI, surgical crics, chest tubes, vents, yadda, yadda, yadda should all be made available.

I'm a coronary Care Unit nurse and all the points above are the rationale for why I lay my patient back for acquisition of a 12 lead. Standing up adipose tissue *hey I'm being polite not to say large amounts of fat lol* droops downwards so it can give misplacements of the leads. Laying flat/flatish, allows the excess to droop to the side allowing adequate placement of the leads in the positions around the heart.

Question though, and I do both techniques dependent on situation.... when you are placing the limb leads, do many people place them on the torso also? Or go for the wrists or ankles. I do both as I said dependent on situation (if my patient is attached to the 12 lead consantly in their initial arrival to the unit, I will use the torso, for intermittant 12 leads and once a day acquisitions, I will use the limbs.)

Scotty

Celticare,

It depends on what you want to do with your ECG. Do you want to monitor or assess? If you just want to monitor, then the torso works fine. RA is close enough when on Right Upper Torso. You won't be able to assess as accurately, but you won't be assessing.

If you want to assess, then you will have to place the leads on the limbs. On assessment, lead placement is paramount. Limb lead placdement on the torso can result in false positive ST elevation. RA means Right Arm.

Hope this helps.

I think I know what happended on this guy. He said he couldn't breathe, started breathing heavy, then stopped breathing, right?

I think he had an anxiety attack (because he's drunk off his ass), started hyperventilating, then passed out and became apneic because he blew his PaCO2 down REAL low. The apnea in reality is a compensatory pause. When their PaCO2 climbs back up, they'll start breathing again.

So, no. He wasn't faking, but it wasn't serious either.

However, you have to treat what you see. You guys did a good job.

What is the main reason why a pt needs to be put from a sitting position into a semi-supine/supine position to do a 12 lead EKG?? Thanks

Also laying down will give you access to properly place the ECG leads. Proper placement is everything.

Who restricts you? Your employer? Ethical Concerns? State Boards? IS Dr. Bledsoe wrong when he has D.O., NREMT-P after his name if he is appearing as a physician? I'm playing kind of devils advocate here I know, but I know plently of Flight RN's who badges say: RN/EMT or RN/EMTP, (FP-C/ RRT also). So is this a standard in your area, or are you stating that this is a national standard? Again, devils advocate here, but if I'm typing it, many are wondering......IMHO

Also bare in mind that they do not write those behind their names on legal documents. That's the key. When Bledsoe writes an order on a pt's chart, he'll write it as "Bledsoe, D.O.".

I think I covered this in an earlier post.