Jwade

Ok, Let me give you the real deal on traction splints.

First, I spent 8 years as a Surgical First Assistant in Trauma Surgery at Detroit Receiving Hospital. Combine that with my 17 years of EMS experience, I can give you an educated and experienced opinion.

Here is what happens when a fractured femur comes into the ER and then to Operating Room.

If patient is on a traction splint, the splint is removed, xrays taken, and usually a traction pin will be inserted into the tibia or distal femur and 20 pound of traction will be applied until patient goes into surgery.

NOW, here is where it gets really interesting and very FEW people know this information.

When the patient comes into the OR, all the traction is removed, the patient is put to sleep, and the desired surgical anatomy is prepped and draped for surgery. Now, imagine if you will YOUR broken leg hanging from the end of a weighted IV pole with kerlex wrapped around your ankle to the IV pole. This is how the legs are prepped with Beta dine and then draped. The legs sits and whatever angle it is broken in on the IV pole.

Someone had mentioned that if the bone would have moved a little the patient would have bleed out....Well, this is not exactly an accurate statement. IF the bone transects ANY major vessel during the INITIAL injury period, then potential huge blood loss is a probability. The chances of an already broken bone causing an IATROGENIC injury during bone reduction and or placement of a splint, or moving to a backboard are statistically NOT significant. Hence, the broken limbs get hung from IV poles.

Once the limb is prepped and draped, we will determine using the C-ARM and xrays, what the best course of action is to fix said bone... Femur fractures will almost 90% of the time receive a femoral nail via the Retrograde or Ante grade approach. If the injury occurs high on the Femur such as the Femoral Neck, then a Hip Screw is needed or a combination of screws, if the Greater Trochanter or Sub-Trochanter is involved, then it gets very complicated, and a combination of a nail, and a blade plate might be required to achieve perfect reduction. The same things goes for the distal femoral condyles, if there is one place you dont want to break on your leg, it is the top or very bottom of your femur........If it is my leg, PLEASE make it a mid-shaft....LOL....

The FEMORAL NECK Fracture is really the only one that must make it to the OR in 6 hours to be fixed emergently or AVN will develop. Any open FX must also go to the OR for at LEAST a washout, and then can return in a couple days to have a definitive fix applied.

fx

Moving on to my Pre-Hospital usage, I might have used them 3 times during 17 years, I think it definitely helps the conscious patient with pain control once properly reduced. Along with generous amounts of Fentanyl and Versed......Fentanyl is the drug of choice due to it's synthetic properties, and the potential transient BP drops associated with MS and the pathophysiology behind it..

Having flown in a few different helicopters, I have had to remove traction splints to be able to get then in the aircraft....This is always entertaining.....Lots of premedication need to happen before you try this maneuver at home.....

Drop me a line if you need any more help, I collaborated with some of my previous surgeons on journal articles, so I am very familiar with the process involved.....

Respectfully,

JW

No, nursing school is the model for good education and new nurses are educated to the highest standards of progressive medicine and current evidence based practice.

Take care,

chbare.

DUDE, Talk about a fallacy of epic proportions!

If Jwade starts thrashing into her, your class might end up like a Harvard Medical school program... he would set her straight.

LMAO...Thanks :-)

Seriously though, I would be more than happy to send her an email, keeping your name completely anonymous of course, and providing her with correct FACTUAL documentation to support both your premise, and to show her conclusions are erroneous. Just send me a PM...

Respectfully,

JW

Ok, I did my part. I gave my vote!

jW

Hey man,

That is an easy one, Just send me her email, and I will be happy to educate her for you.

Sorry, you have to go through this my friend....

Let me know,

JW

Take care,

chbare.

CH,

Great post, Just wondering about your algebraic straight line graphing equation?

Simple Linear Regression

The objective of simple linear regression is to determine the straight-line relationship between a dependent (y) variable and an independent (x) variable. This includes a single explanatory variable, or how much of the variability in the dependent variable (y) can be explained by the independent variable (x). When several explanatory variables exist, a multiple regression analysis is performed. For this paper, three simple linear regression analyses are performed. Linear relationship hypothesis are as follows:

H0 p(rho)=zero

HA p (rho) does not = zero

The author will want to reject the null hypothesis and accept the alternative, or show that there is a linear relationship.

Respectfully,

JW

Vent,

How do you qualify and quantify a satisfactory level of education in EMS? Who determines this?

At what point did I achieve a satisfactory level of EMS education?

EMT-Basic

EMT- I

EMT- P ( All university classes, with A&P, Pathophys, Micro, Organic / Inorganic Chem, Pharm I&II, Nutrition,)

Physiology Degree

Business Management Degree

MBA

MHA

17 years experience

> 1000 flights

CCEMTP, PNCCT, FP-C, ACLS / PALS instructor ..........and the blah blah blah goes on and on....Where is the end point? Am I a statistical Outlier?

Again, I fully agree education is the key, and the people who don't have it, literally dont know what they dont know, but would be interesting to see your response....

Respectfully,

JW

Vent,

Just to play devils advocate with you for a minute, I am confused as to your statement above, Why is is so IRONIC that Cosgrojo chose to get a BS in a non-ems related field....?

I have been in EMS since 1992, moved up through the ranks from EMT-Basic, EMT-I, EMT-P, FP-C blah blah blah, I am 36 now, and just finishing a Double Masters Degree in NON-EMS related fields. MBA / MHA . I have always loved saving lives just as much as the next person, but honestly, we have to truly look at the statistics I think to understand we are rarely saving lives anymore, and have become for the most part expensive taxi rides, and primary care providers.

I always teach and preach having to understand the " WHY" your doing something as opposed to knowing you have to do something, just yesterday in my ACLS class, I had to sit down and explain Cerebral Perfusion Pressure and why a CPP of 42 is bad in an adult. I am PRO education for paramedics, and I agree with 99% of what you say, I just don't see why it is so IRONIC for people such as Cosgrojo and Myself to pursue advanced degrees regardless if they are EMS related or not......

One last thing, CAREER versus JOB debate, these lines are becoming more and more blurred today, society has changed dramatically over the past 50 years and people are no longer willing to be subject to society dictating they MUST pick a career and work it for 30 years, retire, and move to Florida....:-) I read a recent study that showed, todays teenagers will likely have 3 different substantial " Careers" during their adult working life.....I personally regress against the thought that someone must stay in a chosen career field just because they like to do something.....I have multiple passions in life, HEMS, Aviation, Fishing, Cars, and I would be happy to be working in any of them.....

Respectfully,

JW

Just in case anyone was wondering about Fallacies..........

Logical Fallacies

An Encyclopedia of Errors of Reasoning

The ability to identify logical fallacies in the arguments of others, and to avoid them in one’s own arguments, is both valuable and increasingly rare. Fallacious reasoning keeps us from knowing the truth, and the inability to think critically makes us vulnerable to manipulation by those skilled in the art of rhetoric.

What is a Logical Fallacy?

A logical fallacy is, roughly speaking, an error of reasoning. When someone adopts a position, or tries to persuade someone else to adopt a position, based on a bad piece of reasoning, they commit a fallacy. I say “roughly speaking” because this definition has a few problems, the most important of which are outlined below. Some logical fallacies are more common than others, and so have been named and defined. When people speak of logical fallacies they often mean to refer to this collection of well-known errors of reasoning, rather than to fallacies in the broader, more technical sense given above.

Formal and Informal Fallacies

There are several different ways in which fallacies may be categorised. It’s possible, for instance, to distinguish between formal fallacies and informal fallacies.

Formal Fallacies (Deductive Fallacies)

Philosophers distinguish between two types of argument: deductive and inductive. For each type of argument, there is a different understanding of what counts as a fallacy.

Deductive arguments are supposed to be water-tight. For a deductive argument to be a good one (to be “valid”) it must be absolutely impossible for both its premises to be true and its conclusion to be false. With a good deductive argument, that simply cannot happen; the truth of the premises entails the truth of the conclusion.

The classic example of a deductively valid argument is:

(1) All men are mortal.

(2) Socrates is a man.

Therefore:

(3) Socrates is mortal.

It is simply not possible that both (1) and (2) are true and (3) is false, so this argument is deductively valid.

Any deductive argument that fails to meet this (very high) standard commits a logical error, and so, technically, is fallacious. This includes many arguments that we would usually accept as good arguments, arguments that make their conclusions highly probable, but not certain. Arguments of this kind, arguments that aren’t deductively valid, are said to commit a “formal fallacy”.

Informal Fallacies

Inductive arguments needn’t be as rigorous as deductive arguments in order to be good arguments. Good inductive arguments lend support to their conclusions, but even if their premises are true then that doesn’t establish with 100% certainty that their conclusions are true. Even a good inductive argument with true premises might have a false conclusion; that the argument is a good one and that its premises are true only establishes that its conclusion is probably true.

All inductive arguments, even good ones, are therefore deductively invalid, and so “fallacious” in the strictest sense. The premises of an inductive argument do not, and are not intended to, entail the truth of the argument’s conclusion, and so even the best inductive argument falls short of deductive validity.

Because all inductive arguments are technically invalid, different terminology is needed to distinguish good and bad inductive arguments than is used to distinguish good and bad deductive arguments (else every inductive argument would be given the bad label: “invalid”). The terms most often used to distinguish good and bad inductive arguments are “strong” and “weak”.

An example of a strong inductive argument would be:

(1) Every day to date the law of gravity has held.

Therefore:

(2) The law of gravity will hold tomorrow.

Arguments that fail to meet the standards required of inductive arguments commit fallacies in addition to formal fallacies. It is these “informal fallacies” that are most often described by guides to good thinking, and that are the primary concern of most critical thinking courses and of this site.

Logical and Factual Errors

Arguments consist of premises, inferences, and conclusions. Arguments containing bad inferences, i.e. inferences where the premises don’t give adequate support for the conclusion drawn, can certainly be called fallacious. What is less clear is whether arguments containing false premises but which are otherwise fine should be called fallacious.

If a fallacy is an error of reasoning, then strictly speaking such arguments are not fallacious; their reasoning, their logic, is sound. However, many of the traditional fallacies are of just this kind. It’s therefore best to define fallacy in a way that includes them; this site will therefore use the word fallacy in a broad sense, including both formal and informal fallacies, and both logical and factual errors.

Taxonomy of Fallacies

Once it has been decided what is to count as a logical fallacy, the question remains as to how the various fallacies are to be categorised. The most common classification of fallacies groups fallacies of relevance, of ambiguity, and of presumption.

Arguments that commit fallacies of relevance rely on premises that aren’t relevant to the truth of the conclusion. The various irrelevant appeals are all fallacies of relevance, as are ad hominems.

Arguments that commit fallacies of ambiguity, such as equivocation or the straw man fallacy, manipulate language in misleading ways.

Arguments that commit fallacies of presumption contain false premises, and so fail to establish their conclusion. For example, arguments based on a false dilemma or circular arguments both commit fallacies of presumption.

These categories have to be treated quite loosely. Some fallacies are difficult to place in any category; others belong in two or three. The ‘No True Scotsman’ fallacy, for example, could be classified either as a fallacy of ambiguity (an attempt to switch definitions of “Scotsman”) or as a fallacy of presumption (it begs the question, reinterpreting the evidence to fit its conclusion rather than forming its conclusion on the basis of the evidence).

On my last trip to the far east, I had took the opportunity to do ACLS Instructor and a few other little instructors cards. Yesterday the senior ops manager came and asked me for all the stuff cause they wanna open a training facility and need a record of all the instructors they have. I obliged and gave her copies of it which she scanned and sent on to the regional head office.

5min later she gets a mail back from the medical director accusing me of lying because "a paramedic can not be a ACLS instructor, it's reserved solely for MD's". Has things changed in recent months on this or is it just a South African thing?

Thoughts would be appreciated,

Regards

S

This is complete Bullsh&T, as a current ACLS & PALS AHA instructor, and a paramedic, completely erroneous info! In fact, I just taught ACLS this morning, and I had Docs, Nurses, and RT in my class! Hmmmmm

The only one that is tight anymore to get is NRP, very FEW are allowed to get NRP instructor status anymore... back in the day when it was NALS it was pretty easy....

Respectfully

JW

I am a member of our CISD team shoot me a pm I would be more than happy to help you.

Yes, One of our helicopters crashed and killed a friend of mine. We went through the entire CISD stuff. Let me know what I can answer for you.

JW

To the first comment - I'll state let pilots do their jobs, medics do their and while I can definitely appreciate your input from both sides of the fence I have no qualms about telling a pilot I'm not going anywhere if they are pushing weather minimums or I feel my safety jeopardized. I'm sure the vast majority feel the same way. Safety issues addressed, it's their aircraft, and their job to fly it, just as it is my patient, and my job to treat it. I am definitely in agreement though in that the more advanced certifications the better educated you are the more it helps. I have absolutely no argument with that at all. I know it helped me.

Second point - when released from class the first thing I was told - "you know just enough now to kill somebody"...didn't think it at the time, but later realized how very, very true it was.

I fully agree let people do their jobs, the inherent problem is, how many non-pilots can tell the difference between an 800ft & 500 ft ceiling? 3 or 5 mile visibility? Temp / dew point spread? How many of you can look at Nexrad weather and decipher the radar picture in depth? How many people know how to tune in the ILS or Localizer, or read an approach plate properly?

I am all about keeping my a$$ on the ground if weather is closing in, or could deteriorate in route, but too many times people jump the gun and start quoting something they know minimal about, and this includes flying, medicine, sports whatever..... This is what really irritates me to no end.....

VentMedic,

Nice to see you are still ruffling feathers on Flightweb! LOL......Same old crap over there i see! Hope you are well...

Respectfully,

JW

Like nearly everything else discussed here, looking for a universal answer is impossible in this business. We can't even agree on definitions of semester hours. To require anyone in EMS to be a paramedic is simply not practical. Think about the different systems all around the world. Some services operate with a doc on board, some or 2 medics, some are BLS, some are a combination of all of the above. Some areas simply do not have the resources to have an all ALS system. Isn't it better to at least have providers with SOME medical training vs having nothing at all?

As we all know, despite national standards here, all EMS programs are NOT created equal. Some are medic or EMTB mills who's goal is to crank out as many folks as they can. Requiring a degree program is not the answer either. The quality of the instruction is not based on how many classroom hours you put in(although obviously more would probably be better), but the reputation, ability, and character of the instructors and program coordinators.

Even medical schools vary- think about how a doctor who graduates from a Caribbean medical school is viewed by his peers. They could be a brilliant clinician, but will always have a stigma attached to their education.

We could demand that a person must spend an unworldly amount of time in classroom and in training for EMS, and even require a college degree, but unless there is a payoff at the end- ie the person can make a decent wage once they are done, we won't be able to provide enough bodies to fill those spots.

In regards to the highlighted portion of the text......In the most basic terms....NO, Advanced education is the key, and I will probably offend a lot of people on this board in a second when i say, YOU REALLY DONT KNOW, WHAT YOU DONT KNOW!!!!! There is NOTHING worse with someone who has a little bit of knowledge on a subject to start imparting opinions to the masses as if fact......

Unfortunately, I can easily give an example is the world of HEMS.....You take type A medical people, put them on a helicopter or airplane for 1 year, and all of a sudden they are experts on METAR's, Cloud Ceilings, Prognostic charts, Approach plates, and last but not least, think they can fly the aircraft if ever needed in an emergency.....I see it all the time.....This is why you have the inherent in fighting between pilots and medical crew.....It makes for a bunch of second guessing....However, you never see a pilot lean over and say, " Did you really need to Intubate that patient?"

I can speak on both sides because i have the education as BOTH a pilot and flight paramedic! So, the bottom line IMO, Make the EMT-I the new EMT-B, and force all Paramedic programs to a minimum of a 2 year degree, and then give us the option of pursuing the Critical Care Paramedic or Certified Flight Paramedic.....Both latter certs are way beyond the general paramedic and require much more extensive knowledge....I cannot imagine not having taken Pathophysiology, Organic / Inorganic Chem, Pharm I & II, etc.....and be where I am at today....Again, a little bit of knowledge is the scariest thing alive!

I apologize in advance if I offend anyone..Not my intention....

Respectfully,

JW

Hey,

Thanks for the compliment..

Just a quick note, I agree that with regards to scene flights, HEMS rarely offers more than your average ALS truck aside from potentially giving blood, chest tubes, and a few others....The big difference for HEMS comes into play with Critical Care IFT. Managing a critically ill septic patient straight out of the SICU, who is on a balloon pump, Vented, swan, a-line, and 6 drips and put all that crap into a Helicopter is very difficult and challenging even for the most experienced providers...That stuff is definitely beyond the ability of most standard ALS rigs in the USA...

I agree without reservation, HEMS is utilized for scene flights way too much, most ALS providers do a great job on the ground, and during my Rotor years, I would say the chances of me having to redo something the ground guys did was <20% of the time. When I did have to fix something it was usually airway related, a couple crichs that went bad, intubating very small kids, etc.......

So, I would hope most ground guys and gals would seriously take a look at the time commitment needed for calling HEMS, and just get their rig moving in the direction of the hospital.....We can always meet you on the side of the road if necessary.....

Great discussion..

Respectfully,

JW

In response to the OP question....

ABSOLUTELY HEMS is way over utilized!

Having just finishing up an MBA, I can tell you, I have extensively studied the statistics of everything HEMS.....( 3 Graduate Stats classes will force this).

I have to disagree with the above poster, HEMS can easily be a money-maker dependent upon aircraft type, location, time and distance, etc.....

For example,

Take an A-Star B3 , Single Engine, staffed with 4 pilots, 5 nurses, 5 Paramedics for the base.

Average number of flights to cover fixed costs for the month is 16-20 with average reimbursement in the 10 - 15k range.

Lets take my previous rotor base, Airevac 9, We would average 60 flights month.

60 * 15k = 900,000 dollars gross

subtract your 20 flights to cover fixed costs, ( Salaries, DOC,etc...)

leaves you with avg of 40 flights @ 10-15k.

this will leave you with a net income of 400,000 - 600,000 dollars a month.....NOW, you throw up 10 more bases on every street corner like there is in Arizona, and do the simple math......You tell me if it loses money or not..... ( NOT)

Why do you think the amount of helicopters has quintupled in the last 7 years? This would not happen if there were not money to be made.....

Again, each company will be different based on aircraft, reimbursement rates etc......

Arizona is by FAR the worst offender of flying patients who have no business being flown.....Many of the ground crews do not want to make the drive into Phoenix, especially during rush hour, so they just say fly them out, regardless of appropriate........This is one of the main reasons I left Rotor wing and went to Graduate School.....

having moved to AZ from Michigan, where there is such strict criteria for using a helicopter was a huge shock to me.....In all my time working the ground in Southeastern Michigan, I called for a helicopter twice......Once for a 95% burn patient who was 45 min from ANY hospital, and the other was a very prolonged ICE rescue from Lake huron.

We were expected to take care of our patients, and not punt them off to the quickest taxi ride available......It is just absolutely asanine out here in AZ.....There are over 25 helicopters in the METRO phoenix area.......Do you really think there are that many patients who need Air Transport?

The studies prove >75% of the patients who are flown DO NOT need HEMS......75% you tell me what is wrong with this picture!!!!!!

From this proliferation has come a detriment to the HEMS provider, the talent pool has been watered down to nothing more than a BP and a pair of boots, and a license.......Back in the day, one would have to have a minimum of 10 years experience, instructor status in everything known to man, someone would have to die in the flight program or retire for a spot to open up......and then you would pray you had an inside friend to make a recommendation for you.....

Respectfully,

JW

Which hospital(s) and when?

Hey, I started initially working in the O.R. at Hutzel Hospital, and then transfered to the legendary Level 1 Detroit Receiving Hospital. I was there from 1996 -2004.

I also worked contingent at a few other hospitals in the area as well, Henry Ford, Bon Secours, and St.Joes West.

JW

This nurse obviously has no idea what she is talking about. The literature shows that giving pain medication does not interfere with the exam, in fact it has been shown to improve the accuracy of the exam. Even if you are in the hospital bay, give pain meds. In the time it takes for the pt to get into the hospital, onto the hospital strecher, triaged, wallet biopsied, etc, more meds will have had time to work. I'd recommend keeping a file of studies on the ambulance to show to hospital staff that have no idea what they are talking about. Here are a few to get you started.

http://www.ncbi.nlm.nih.gov/pubmed/17636812?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedreviews&logdbfrom=pubmed

http://www.ncbi.nlm.nih.gov/pubmed/17032990?ordinalpos=11&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1070812

That should be enough to get you started. Spenac, I'd make it a point to make sure this nurse got copies of these (as well as the doctor if he/she did in fact complain).

Excellent articles for people to keep with them in the rig or helicopter for sure.....No pain management for these patients was very prevalent in the 70's - 90's, however with the advancement of technology and 64 slice CT scanners, there is absolutely NO reason to withhold pain meds.....I have no doubt some attorney could make a strong case for negligence or malpractice.

Having spent 8 years as a First Assistant in Trauma Surgery in Detroit, I can categorically say, none of the Trauma Surgeons would ever hold pain meds so they could " Examine" the patient properly.....

Respectfully,

JW

Yes I too wonder about this too, in animal labs with an intact aortic valve we attempted to produce a retro flow as suggested in the CPR lit studies although the coronary artery are distal to the aortic valve the question remains with autoregulation of BP and subsequent loss of control (of the container) and darn near zero for SVR in an arrest I suspect.

It does become a quandary that the brain survives on occasions really with such low CPP.

Perhaps more alpha specific drugs would be adventitious to a positive outcome ? Do I dare suggest Levo ? Duck, weave and runs for bunker

Sure wish I had a Doppler US to take a peek of what is really going on.

cheers

Norepinephrine has been studied in only a limited fashion for treatment of cardiac arrest. Human data is limited, but it suggests that norepinephrine produces effects equivalent to epinephrine in the initial resuscitation of cardiac arrest.53,103 In the only prospective human trial comparing standard-dose epinephrine, high-dose epinephrine, and high-dose norepinephrine, the norepinephrine was associated with no benefit and a trend toward worse neurologic outcome (LOE 1).53

Epocrates

ABG

Acid Plus

Eponyms

Netters Anatomy

Vasopressin

Vasopressin is a nonadrenergic peripheral vasoconstrictor that also causes coronary and renal vasoconstriction.58,59 Despite 1 promising randomized study (LOE 2),60 additional lower-level studies (LOE 5),61–63 and multiple well-performed animal studies, 2 large randomized controlled human trials (LOE 1)64,65 failed to show an increase in rates of ROSC or survival when vasopressin (40 U, with the dose repeated in 1 study) was compared with epinephrine (1 mg, repeated) as the initial vasopressor for treatment of cardiac arrest. In the large multicenter trial involving 1186 out-of-hospital cardiac arrests with all rhythms (LOE 1),65 a post-hoc analysis of the subset of patients with asystole showed significant improvement in survival to hospital discharge but not neurologically intact survival when 40 U (repeated once if necessary) of vasopressin was used as the initial vasopressor compared with epinephrine (1 mg, repeated if necessary).

A meta-analysis of 5 randomized trials (LOE 1)66 showed no statistically significant differences between vasopressin and epinephrine for ROSC, 24-hour survival, or survival to hospital discharge. The subgroup analysis based on initial cardiac rhythm did not show any statistically significant difference in survival to hospital discharge (LOE 1).66

In a large in-hospital study of cardiac arrest, 200 patients were randomly assigned to receive either 1 mg of epinephrine (initial rhythm: 16% VF, 3% VT, 54% PEA, 27% asystole) or 40 U of vasopressin (initial rhythm: 20% VF, 3% VT, 41% PEA, 34% asystole). There was no difference in survival to 1 hour (epinephrine: 35%, vasopressin: 39%) or to hospital discharge (epinephrine: 14%, vasopressin: 12%) between groups or subgroups.64

A retrospective analysis documented the effects of epinephrine alone (231 patients) compared with a combination of vasopressin and epinephrine (37 patients) in out-of-hospital cardiac arrest with VF/VT, PEA, or asystole. There was no difference in survival or ROSC when VF or PEA was the presenting rhythm, but ROSC was increased in the epinephrine plus vasopressin group among patients presenting with asystole.67

Because vasopressin effects have not been shown to differ from those of epinephrine in cardiac arrest, one dose of vasopressin 40 U IV/IO may replace either the first or second dose of epinephrine in the treatment of pulseless arrest (Class Indeterminate).

60. Lindner KH, Dirks B, Strohmenger HU, Prengel AW, Lindner IM, Lurie KG. Randomised comparison of epinephrine and vasopressin in patients with out-of-hospital ventricular fibrillation. Lancet. 1997; 349: 535–537.[CrossRef][Medline] [Order article via Infotrieve]

61. Lindner KH, Prengel AW, Brinkmann A, Strohmenger HU, Lindner IM, Lurie KG. Vasopressin administration in refractory cardiac arrest. Ann Intern Med. 1996; 124: 1061–1064.[Abstract/Free Full Text]

62. Mann K, Berg RA, Nadkarni V. Beneficial effects of vasopressin in prolonged pediatric cardiac arrest: a case series. Resuscitation. 2002; 52: 149–156.[CrossRef][Medline] [Order article via Infotrieve]

63. Morris DC, Dereczyk BE, Grzybowski M, Martin GB, Rivers EP, Wortsman J, Amico JA. Vasopressin can increase coronary perfusion pressure during human cardiopulmonary resuscitation. Acad Emerg Med. 1997; 4: 878–883.[Medline] [Order article via Infotrieve]

64. Stiell IG, Hebert PC, Wells GA, Vandemheen KL, Tang AS, Higginson LA, Dreyer JF, Clement C, Battram E, Watpool I, Mason S, Klassen T, Weitzman BN. Vasopressin versus epinephrine for inhospital cardiac arrest: a randomised controlled trial. Lancet. 2001; 358: 105–109.[CrossRef][Medline] [Order article via Infotrieve]

65. Wenzel V, Krismer AC, Arntz HR, Sitter H, Stadlbauer KH, Lindner KH. A comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J Med. 2004; 350: 105–113.[Abstract/Free Full Text]

66. Aung K, Htay T. Vasopressin for cardiac arrest: a systematic review and meta-analysis. Arch Intern Med. 2005; 165: 17–24.[Abstract/Free Full Text]

67. Guyette FX, Guimond GE, Hostler D, Callaway CW. Vasopressin administered with epinephrine is associated with a return of a pulse in out-of-hospital cardiac arrest. Resuscitation. 2004; 63: 277–282.[CrossRef][Medline] [Order article via Infotrieve]

Dwayne, I think what he is trying to say is that you will have backflow of blood through the venous system leading to the production of a pulsation in the femoral vein. It has me thinking. Could we use ultrasound to assess for arterial flow so that we could differentiate between a venous and an arterial pulsation? That being said, having run a few codes, Ive put in a central line or two. To put a central line in the femoral vein, you feel for the femoral artery and go medial. Every code I've had where I placed a central line, I've been able to palpate a pulse and have found a large vein medial to it. Makes me wonder.

ERDoc,

I will try using the Sonosite the next time I drop a Femoral Line during a code to see if your premise is correct. It makes me wonder as well. One of my main thoughts on the subject is having worked as a First Assist in Trauma Surgery in Detroit, I have done countless IAM / IVM with contrast and I just have not seen all that much forward flow going on, even when we had an open chest and I was doing open cardiac massage with my hands and watching on the C-ARM.

It would make for an interesting animal study i think.

Dwayne,

I think if you pull up the following study off Medline and read in entirety, it should help to clarify things for you about how Retrograde Anatomy and Flow can cause Femoral Pulsations.

Connick M, Berg RA. Femoral venous pulsations during open-chest cardiac massage. Ann Emerg Med. 1994; 24: 1176–1179.

Respectfully,

JW

Cosgrojo,

Points taken!

So, let me try to simplify what I was asking.

1. Do you use Femoral Pulse checks to gauge CPR adequacy?

2. If " YES" please provide your rationale and literature.

3. If " NO" please explain your procedure and why.

4. What is your background and education.

5. Do you actually spend time reading and understanding current research literature?

Again, Sorry for the confusion, I was not trying to flame anybody.

I ask these questions because it is my experience having worked from the streets of Detroit to flying the friendly skies, when I ask a provider " WHY" he or she usually will say either, " that is what I was taught" or "that is the way we have always done it".

Respectfully,

JW

Et al...

First, I was not trying to start a flame war by any means. However, I do not like people who state something as FACT and then cannot back it up with proven scientific evidence.

I was always taught from DAY one in EMT BASIC school way back in 1992 that checking a femoral pulse was pointless.

1. Cardiac Output is 20% at best of normal

2. Finding Femoral Pulses in people is a difficult task many times even with Normal Cardiac Output.

The reason I started this thread stemmed from a discussion / debate with an M.D. as I was teaching an ACLS course. A second reason I started the thread was having just finished an MBA program and having spent way too many hours looking at various HEMS / EMS statistics I was curious as to what the majority of responses would be, and from what background and education. (I.E. Street Paramedic, Flight Paramedic, EMT, Nurse, etc.....) I am more interested in the statistics.

After pulling up the various studies which show femoral pulses during CPR = Retrograde Flow this physician has since changed his lectures to include this info to students.

So, I am just curious as to what you guys do and WHY? Do you do it because that is what " we have always done" or " this is what i was taught" or do you alter your practice based on current literature?

Also, I was not limiting the discussion to PRE-Hospital, I see many nurses checking femoral pulses in the ER during codes. I completely understand if you are limited in what you carry on the RIG due to medical direction and so forth. As a Flight Paramedic, we pretty much have every toy at our disposal, and waveform ETCo2 is used extensively in many different aspects of our patient care, especially when we are running on a vent.

Anyways, I apologize if I offended anyone, it was not my intention. Also, Where did I make an assumption? I simply stated " ONE " must have a good working knowledge of A & P, I did NOT single any individual person out.

Look forward to your continued responses.

Respectfully,

JW

PS. MOBEY, What are you using for ETCo2? EasyCap or Waveform? There is a HUGE difference.

Herbie,

First, Please don't regurgitate a bunch of anecdotal stories you have been taught your whole life. If one knew anything about anatomy and physiology one would understand that trying to feel a femoral pulse during the presence of CPR ( when cardiac output is at most 20% or normal) is nothing more than RETROGRADE BLOODFLOW! Again, one has to have a good understanding of what NORMAL anatomy is all about.

For your reading pleasure.

(Circulation. 2005;112:IV-78 – IV-83.)

© 2005 American Heart Association, Inc.

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

8. Connick M, Berg RA. Femoral venous pulsations during open-chest cardiac massage. Ann Emerg Med. 1994; 24: 1176–1179.

Assessment During CPR

At present there are no reliable clinical criteria that clinicians can use to assess the efficacy of CPR. Although end-tidal CO2 serves as an indicator of cardiac output produced by chest compressions and may indicate return of spontaneous circulation (ROSC),1,2 there is little other technology available to provide real-time feedback on the effectiveness of CPR.

Assessment of Hemodynamics

Coronary Perfusion Pressure

Coronary perfusion pressure (CPP = aortic relaxation [diastolic] pressure minus right atrial relaxation phase blood pressure) during CPR correlates with both myocardial blood flow and ROSC (LOE 3).3,4 A CPP of 15 mm Hg is predictive of ROSC. Increased CPP correlates with improved 24-hour survival rates in animal studies (LOE 6)5 and is associated with improved myocardial blood flow and ROSC in animal studies of epinephrine, vasopressin, and angiotensin II (LOE 6).5–7

When intra-arterial monitoring is in place during the resuscitative effort (eg, in an intensive care setting), the clinician should try to maximize arterial diastolic pressures to achieve an optimal CPP. Assuming a right atrial diastolic pressure of 10 mm Hg means that the aortic diastolic pressure should ideally be at least 30 mm Hg to maintain a CPP of 20 mm Hg during CPR. Unfortunately such monitoring is rarely available outside the intensive care environment.

Pulses

Clinicians frequently try to palpate arterial pulses during chest compressions to assess the effectiveness of compressions. No studies have shown the validity or clinical utility of checking pulses during ongoing CPR. Because there are no valves in the inferior vena cava, retrograde blood flow into the venous system produce femoral vein pulsations.8 Thus palpation of a pulse in the femoral triangle may indicate venous rather than arterial blood flow. Carotid pulsations during CPR do not indicate the efficacy of coronary blood flow or myocardial or cerebral perfusion during CPR.

Assessment of Respiratory Gases

Arterial Blood Gases

Arterial blood gas monitoring during cardiac arrest is not a reliable indicator of the severity of tissue hypoxemia, hypercarbia (and therefore the adequacy of ventilation during CPR), or tissue acidosis. This conclusion is supported by 1 case series (LOE 5)9 and 10 case reports10–19 that showed that arterial blood gas values are an inaccurate indicator of the magnitude of tissue acidosis during cardiac arrest and CPR both in and out of hospital.

Oximetry

During cardiac arrest, pulse oximetry will not function because pulsatile blood flow is inadequate in peripheral tissue beds. But pulse oximetry is commonly used in emergency departments and critical care units for monitoring patients who are not in arrest because it provides a simple, continuous method of tracking oxyhemoglobin saturation. Normal pulse oximetry saturation, however, does not ensure adequate systemic oxygen delivery because it does not calculate the total oxygen content (O2 bound to hemoglobin + dissolved O2) and adequacy of blood flow (cardiac output).

Tissue oxygen tension is not commonly evaluated during CPR, but it may provide a mechanism to assess tissue perfusion because transconjunctival oxygen tension falls rapidly with cardiac arrest and returns to baseline when spontaneous circulation is restored.20,21

End-Tidal CO2 Monitoring

End-tidal CO2 monitoring is a safe and effective noninvasive indicator of cardiac output during CPR and may be an early indicator of ROSC in intubated patients. During cardiac arrest CO2 continues to be generated throughout the body. The major determinant of CO2 excretion is its rate of delivery from the peripheral production sites to the lungs. In the low-flow state during CPR, ventilation is relatively high compared with blood flow, so that the end-tidal CO2 concentration is low. If ventilation is reasonably constant, then changes in end-tidal CO2 concentration reflect changes in cardiac output.

Eight case series have shown that patients who were successfully resuscitated from cardiac arrest had significantly higher end-tidal CO2 levels than patients who could not be resuscitated (LOE 5).2,22–28 Capnometry can also be used as an early indicator of ROSC (LOE 529,30; LOE 631).

In case series totaling 744 intubated adults in cardiac arrest receiving CPR who had a maximum end-tidal CO2 of <10 mm Hg, the prognosis was poor even if CPR was optimized (LOE 5).1,2,24,25,32,33 But this prognostic indicator was unreliable immediately after starting CPR in 4 studies (LOE 5)1,2,32,33 that showed no difference in rates of ROSC and survival in those with an initial end-tidal CO2 of <10 mm Hg compared with higher end-tidal CO2. Five patients achieved ROSC (one survived to discharge) despite an initial end-tidal CO2 of <10 mm Hg.

In summary, end-tidal CO2 monitoring during cardiac arrest can be useful as a noninvasive indicator of cardiac output generated during CPR (Class IIa). Further research is needed to define the capability of end-tidal CO2 monitoring to guide more aggressive interventions or a decision to abandon resuscitative efforts.

In the patient with ROSC, continuous or intermittent monitoring of end-tidal CO2 provides assurance that the endotracheal tube is maintained in the trachea. End-tidal CO2 can guide ventilation, especially when correlated with the PaCO2 from an arterial blood gas measurement.

Cheers.

John Wade MBA, FP-C

Everywhere I have run a code has used EKG waveform during CPR and the presence of a femoral pulse...

I know I'm new and blond, but how does ETCO2 tell you CPR is being performed adequately? I thought that was used to determine if ventilation were adequate? And yes, ventilation is one part of CPR... is there another use for it?

I am curious to see these studies about the femoral pulse checks in CPR... I would think that if a femoral pulse is present, adequate perfusion to the brain was occurring?

Kate,

There is nothing wrong with being new and certainly not blonde. :-)

It only means you have limited experience, and probably no critical care experience. Again, nothing wrong..

Your BLOOD PRESSURE is going to be the only reliable means of brain perfusion. Remember NORMAL CPP ( cerebral perfusion pressure is 70 for an adult.

We can calculate CPP by taking your MAP - ICP = CPP Mean arterial pressure - Intercranial pressure = Cerebral Perfusion Pressure

SO, For example, if you have someone with a ROSC, and a BP of 60 / 40. What is your CPP?

Calculate MAP is Systolic + 2* Diastolic / 3

60+80 = 140 / 3 = MAP 46.6

Obviously we cannot calculate ICP without a bolt sticking out of the head, but a reliable estimate in a NON-Head Injured patient is 10% of your MAP. So a Map of 46 gives you 4.6

MAP - 46.6

ICP - 4.6

= CPP = 42 SO, we know that NORMAL adequate perfusion of CPP is 70, with the above BP you are at 42. It goes without saying, you are not doing a whole lot for his brain perfusion with a CPP of 42.......

As far as ETC02 is concerned, THERE is a TON that WaveForm ETCo2 can tell someone. Again, this is far above your average 911 paramedic level training, but once you learn it and how to apply it in critical care settings, you will always want it......:-)

Let me know if you have any questions.

Respectfully,

John Wade MBA, FP-C

Pain Relief in Arizona in the order I reach for it.

Fentanyl

Morphine

and they keep getting it until they are pain free or not breathing.

JW