Camulos

THANK YOU!!!!!!!!! Someone finally gets it. Give me the scenario and I'll tell you what I would do. Certainly does not subscribe to the theory that "an arrest is an arrest, is an arrest" Stay safe, Curse :evil:

As I said I often amuse myself. And indeed I have here with your hair reference. As I stated before, once is a typo. I have NEVER claimed to be immune from them and even commented I make them all the time. However when I spell TREES incorrectly three times, as genAric (sic) was, well then I would agree you have a point. It wasn't the typo / spelling I was pointing out though. It was the repetitive mistake that was still not corrected despite being GIVEN the correct spelling. Having said that though Wendy I certainly do hope that your 1356 messages to date contain PERFECT spelling and grammar. It's going to take a while for me to search them though. I hope they are certainly all clinically correct too!!! But that is another time. For now, I'm going back to walking through a woman's hair. - Stay safe, Curse :evil:

Come on guys and gals. Why is a 22G IVC not ideal in the trauma pt. Remember I'm after the law!! Another hint : This law also explains the primary reason why a CVC is not indicated in the initial management of the trauma pt. Stay safe, Curse :evil:

I don’t know how I lost YOUR point. I personally thought you did a pretty good job losing it yourself. I am sorry you feel that I have HIJACKED this thread. But that is the way YOU feel and I have no real control over that. It was certainly not my intention to HIJACK here and I just wanted Phil to be able to recognise his earlier statement was near sighted. Or do you agree that an arrest, is an arrest, is an arrest? :roll: Getting back to this original post – would I stop and treat or continue and run? Give me the clinical picture of the pt and I’m happy to provide my answer. I guess that is what I was alluding to when I wanted further info initially before committing to an answer. I love the forest and the trees it is made up of. Unfortunately in an attempt to get through the forest I think you must keep walking into the tress as you are making the SAME mistake. – it’s genEric for god sake!!!!! I’m am of course joking when I write this stuff. Spelling mistakes are a part of life. I just find some spelling mistakes amusing – especially when repeated. As I said sometimes I even amuse myself. Stay safe, Curse (AKA Hijacker) :evil:

I assume this still centres around the main point of whether to give cardizem or not. As such my answer to that question is still NO – I would not give it based on the limited info you gave me. First and foremost my main reason here is that my protocols don’t allow me too in the present situation you outline. So in that sense I would be stupid, and indeed reckless, to deviate from them. I guess the other question is; do I think this protocol is correct? Well this is the area that is open to debate and I am happy to give you my personal feelings on the case. In your scenario we are 3 hours from hospital. That in itself does cause concern and generally when placed in that situation I believe we feel we need to do something more definitive for the pt as the hospital is so far away. In some circumstances and scenarios there is certainly a valid reason to provide care that we might not otherwise provide if the ED was just around the corner. In this case though I am happy that the protocol says NOT to give the cardizem at this stage. My reason for this is that the pt is not exhibiting overt physical signs of cardiovascular compromise. Don’t get me wrong, the ventricular rate of 200bpm would certainly concern me and I would be monitoring this pt quite judiciously. Damn – I’m in for a long three hours. Now if we are talking about the original pt in this thread and applying them to this scenario I would suspect that this particular pt , who from memory was in their seventites, would not be able to sustain this rapid ventricular rate for very long before the physical signs started to manifest. When the physical signs start to show in the pt well then I could consider treatment with cardizem providing my protocol criteria were fulfilled. I would also wonder why there was such a mismatch between the monitor and the pt. We spoke earlier about the high probability of this pt being on beta blockers. I guess this may be one possible cause of why the physical signs are not manifesting themselves. However in this situation the answer on cardizem is again very simple. I would NOT give it here if the pt was on beta blockers. I feel the risk of profound hypotension and complete AV nodal block is just too great. I guess at different points during any scenario, the treatment we provide all comes down to a risk v benefit analysis. I feel that the risks associated with giving the cardizem at a pulse rate below 100bpm outweigh the benefits and therefore feel it is appropriate to not give it. There are other physical signs I would obviously take into consideration when making this decision of course but this was the only one I was provided with. I must stress though that I understand the decision to not give the cardizem is fraught with danger. Even though the pt is stable now, well as far as physical clinical signs go, does not mean they are just going to fall in a complete heap. In my experience this is usually not the case with adults and instability is a progressive process, in this sort of scenario anyway. There are always exceptions to this rule though that come up and bite you on the arse and this rule does certainly NOT apply to trauma or children. Those little buggers compensate so well for so long and then it all just turns to crap. :x If this pt were to completely drop her bundle well I guess you are faced with a situation of whether to cardiovert or not. The indications for this are pretty rigid though and it is usually not a hard decision to make when the signs are there. Don’t get me wrong, I would have HUGE reservations cardioverting this pt – particularly if not normally on anticoagulants.. However sometimes you just find yourself in a crappy situation and have to do what you have to do. I’ve ranted on enough and have to get ready for work now. Hope this answer has stimulated some further discussion here as I have certainly enjoyed this topic so far. Stay safe, Curse :evil:

If I go hypo around crotch I REALLY hope he gets that IV in!!!! :oops: Out of interest have you ever had to actually do this? If so, was it effective? Stay safe, Curse :evil:

I don't know what genAric is however guess you mean genEric. We all have typos - I am certainly not immune to that. However although once can be a typo, twice is amusing!!! Indeed sometimes I even amuse myself. I would appreciate a more detailed description of what you mean by the above statement - particularly "circle talk". I am fully cognizant of the fact that I am staying quite non committal on this particular topic and indeed do so with purpose. Rather than BLUNTLY pointing out where I feel Phil is incorrect I am attempting to get him to recognise what I believe is his erroneous statement himself. I feel Phil, and perhaps others, may get more out of it that way. Getting back to the clinical issue then. What would you do tniuqs if the pt was in a shockable rhythm? Keen to hear your answer. Hopefully it's not a genAric one!!! Stay safe, Curse :evil:

I would have huge reservations adopting this practice. I guess in the scenario you would have given the cardizem then as it is exactly the situation you describe above. I firmly believe that I would NOT give the cardizem in this particular pt and think you may open up a whole can of worms if you do. Indeed my established protocols would prohibit me from administering it anyway as the PULSE is less than 100bpm. So I can wash my hands of that one. You state that you would be happy to give the cardizem if the pulse rate was within normal range but the monitor was ehibiting a RVR. I assume by "normal" rate you mean 60 - 100bpm. That being the case I am interested to know, would you be happy to give cardizem to a pt with a PULSE of 60bpm who exhibited a RVR on the monitor :?: Interested to read your response. Stay safe, Curse :evil:

LOL Not the equation or law I had in mind but it did however did give me a good laugh. So what is the law I am thinking of? Stay safe, Curse :twisted: I thought a laughing evil was more appropriate this time!!

Hey Phil, Don't think of it as being "taken to task". Our main focus on these forums is to discuss and debate issues so we may provide quality care for our pts. If we can ALL learn something on these forums then they have definitely served their purpose. So rather than "taken to task" let's call it "taken to class". The main statement I had a problem with earlier was; I believe this approach to be extremely near sighted. Although certain aspects of arrest management may have common themes and approaches, the clinical spectrum of arrest management is by no means anywhere near that generic. As we have already seen from earlier posts, there are occassions where it is appropriate to treat in the ambulance as well as situations where it is more appropriate to run into the ED. One such scenario, which has been debated so far, specifically centres around whether the pt is in a "shockable" rhythm or not - hence my first question. So Phil, is the validity of this question now apparrent to you? And do you still believe that an arrest is an arrest is an arrest? As for the other debate. If the pt has arrested in a shockable rhythm, I feel the answer here is quite established by international protocol. I don't want to spoil it though but will say that hopefully someone can bear WITNESS to it for us. CLUE CLUE CLUE. :wink: Looking forward to your answers Phil and sincerly hope you have had a change of heart. Stay safe, Curse :evil:

"Wrong, wrong, wrong" and "There is nothing wrong" Is that a contradiction???? LOL I do however understand your main contention that far too many medics / doctors / nurses etc believe they will not get a cannula in a dialysis pt even before they have tried. Whatever happened to the power of positive thought people? My next questions - 1) Would you be happy with a 22G IVC in a trauma pt? 2) If not why not? Hint - a simple equation or law here will suffice 3) Alternatives? 4) Methods of insertion and possible insertion sites? Don't ask much do I? :roll: Looking forward to the responses. Stay safe, Curse :evil:

Well for me it makes a HUGE difference. Even the presenting rhythm can make a HUGE difference to my decisions here. I can outline numerous different arrest situations where the clinical condition would alter my approach. That is for later though. For the moment I must assume that you have a stock standard approach you would apply in EVERY arrest scenario. As such I would appreciate if you could answer the question - Do you stop the ambulance and treat or do you continue on? As you obviously believe arrest management is so generic this answer must apply to ALL arrest scenarios. Once you answer I'll give you some scenarios and we will examine whether your ONE approach is applicable in every situation. After all as you state "An arrest is an arrest". :roll: Eagerly awaiting your answer. But I suspect you may have already changed your mind and won't give me ONE. If you do answer though keep this in mind "Tis the prettiest little parlor that ever you may spy." Let the back pedalling begin!! Stay safe, Curse :evil:

Interesting case. And highlights the reason why I stated earlier that ANY changes in the inferior leads mandates a right sided ECG. Hell let's do one on everybody at triage regardless of what they present with. Sore finger = R sided ECG, headache = R sided ECG, visiting a relative = R sided ECG. I'm joking of course. But it is important to remember to do one when ANY anomalies appear in the inferior leads. Stay safe, Curse :evil:

What sort of arrest? Shockable rhythm or not? Stay safe, Curse :evil:

So it's those damn interventional cardiologists doing it!!! :roll: Good to see they are raising the profile of isolated RVI by increasing its incidence. Stay safe, Curse :evil:

The youngest I have stuck was around 7-8 years. Did it with a standard 14G. In hindsight this pt may not have had a TP however the signs were there so what is one to do? He certainly did have a pnemothorax after I was done making him into a dart board. Oops – Aren’t we supposed to follow the dictum Primum non nocere. :oops: But that’s another story and shall be told another time. Back to this topic. I do wonder about how to safely decompress much younger children. I would assume that the length of the cannula used is probably irrelevant, as long as you are sensible and only insert as far as required to decompress a tension. I wonder whether the bore of the needle would be too big for say a six month old. I guess the gauge of needle would only theoretically be too big if it did not fit into the intercostal space where you were inserting it. On that measurement alone I don’t believe even a 14G would be too big. Having said that I’m looking at a 14G right now thinking I would have HUGE reservations sticking that in a six month old. I noticed someone earlier state they used a 20G. My personal feeling is that a 20G may be too small. But it worked, so hey what do I know? I guess the correct answer might be somewhere between 14 – 18G. However it would be good to get some actual documentation on this though so I don’t have to rely on my “guesses”. Good question tskstorm as it has made me prepare for a situation I have luckily not encountered before. Better than sweating it at the time that’s for sure!!! Whilst on this topic I wanted to raise another question. How do you detect a tension pneumo in an infant? Interested to read the answers. Stay safe, Curse :evil:

True indeed. Perhaps not as rare as the second article reports though. In this article it states ; "The previously reported incidence of isolated RVI is very low (< 0.5% of all myocardial infarctions).4." If I have read the reference list correctly, this < 0.5 % incidence of isolated RVI comes from a 1992 study. This low figure, at the time this article was published, was possibly due to the fact that isolated RVI may have not been recognised - not because it was not occurring. Although RVI was first postulated in the late 40's it still didn't really gain much kudos until the late 90's. Some might argue it has still not gained worthy recognition as a significant clinical entity. I, with others, published an article in 2002 on isolated RVI. In quite an exhausting literature search we found the incidence anywhere within the range of <1% to around 10% of all MI's. So perhaps it is more common than once thought - and the reasons for this are multifactorial. Regardless of how prevalent isolated RVI is I believe the important point to note is that it is crucial to recognise when it DOES occur - so that <1 - 10% of the time. Standard MI treatment, assuming LVI, can be quite detrimental to a pt suffering isolated RVI. As a standard, I strongly believe that any inferior changes on an 12 lead ECG should mandate a right sided ECG paying particular attention to V3R and V4R. Also in the second article I noticed this statement; "However, the incidence could be underestimated and the increasing application of primary PCI as a reperfusion strategy in acute myocardial infarction will likely result in a higher actual incidence of this infarct location." I don't understand how primary PCI increases the INCIDENCE of isolated RVI. I can understand how it may increase the RECOGNITION of isolated RVI however maybe I am missing something. Can someone please enlighten me? :? So I guess my message when dealing with isolated RVI - GET IT RIGHT!!!! Stay safe, Curse :evil:

I see where you are going with your posts overall p3medic however this particular statement is unfortunately incorrect. There are cases where isolated RVI has exhibited ST elevation in the precordial leads, including V4. Here’s one such case ; Ilia R, Margulis G, Goldfarb B, Katz A, Rudnik L, Ovsyshcher IA: ST Elevation in Leads V1 to V4 caused by isolated right ventricular ischeamia and Infarction. Cardiology 1987;74:396-399 Having said that I must point out that elevation in lead V4, even accompanied by inferior ST elevation is USUALLY not specifically diagnostic for ISOLATED RVI. Notice I say USUALLY!!! After all the article above shows it can happen. In my experience though, the elevation in lead V4 more often than not suggests it is NOT an isolated RVI and highly raises the probability of left ventricular wall involvement. So whilst elevation in lead V4 MAY be associated with isolated RVI I believe this is the exception rather than the rule. Elevation in lead V4R however certainly has much more of a higher probability for isolated RVI. Certainly if I were a betting man and had to lay a bet on which lead was more specific for a diagnosis of isolated RVI, I would go with V4R. Then again on the rare occasions I have placed a bet I usually lose my money. Perhaps there's a lesson there!!! Stay safe, Curse :evil:

If only it were that simple. Out of interest crotch how would you have dealt with the scenario I put in my earlier posting of the person trapped in the car with the only access being the lower half of the arm with an AV fistula? PS. Trunk monkey is cool!!! Stay safe, Curse :evil:

Unfortuantely I disagree with this one too. You can TECHNICALLY get an atrial rate from AF. It is extremely difficult though and even using advanced methods does sometimes come up as "umeasurable" - depending on certain factors. As you want references here you go; http://www.cinc.org/Proceedings/2008/pdf/0829.pdf I do recognise this is a moot point though and is not clinically significant for us at the bedside as we do not have the ability to measure the atrial rate as they did in this article. Who knows, perhaps Welch periodogram's will become standard in all ambulances and ER's. :wink: Stay safe, Curse :evil:

I fully agree we should treat pt's and not monitors - NO argument there. In fact I am constantly pulling people up for that very problem. You would be amazed how many people commence treatment on an asystole algorhythm when I sneakily (is that a word?) remove the electrodes during scenario training. Having subsequently just read the clinical obs of this pt, HR 88bpm and BP 130mmHg, the correct decision would be NOT to give the cardizem. Comes back to the contraindications I mentioned earlier. I guess CTXMEDIC was just asking for more info before deciding whether to give the cardizem or not. And that information was critical in this case, so in that sense he was ultimately correct in making the decision not to give cardizem before assessing the pts pulse rate. Unfortunately I think it is sometimes difficult to decipher his real point amongst all the politics. I'm not having a go here though and believe it takes all sorts to make a world, or a forum topic. At the very least he keeps it interesting that's for sure. Great topic and I'm sure we all learnt a lot from it. Stay safe, Curse :evil:

To answer the question, yes it can be done. Of course whether you are permitted to do it is another question and depends on a few factors. Local protocols, training, pt need etc. I must stress that I would only ever consider this an absolute last resort. Therefore several failed IV and IO attempts would have to have occurred and the pt would have to be unwell enough to warrant such a drastic measure. And providing the pt has limbs, I can’t see why I would stuff up the IO. Given your scenario was a cardiac arrest one I guess it is also important to keep in mind that certain arrest drugs can be placed down the ETT if IV / IO access truly is a problem. If you are to access the fistula a few things to keep in mind; • Make the procedure as clean as possible. I recognise that this may be difficult in this situation however AV fistulas are particularly prone to infection. No use saving the pt now only to have them die from overwhelming sepsis from an infected fistula. • Must be a last ditch option. All other options have been exhausted and the pt is moribund. • If the pt has a fistula they already have renal failure. Keep this in mind when making any decision to infuse a large volume of fluids. • Because the pressure in the fistula can be quite high you may need to infuse fluid under pressure. If a pressure bag is not available a BP cuff around the fluid bag may suffice. But beware applying too much pressure and “blowing” the fistula. Don’t use any smaller than a 10ml syringe because of the high pressures they apply and for some reason a maximum of 150mmHg comes to mind when using a pressure bag / BP cuff. I have no idea where I got that from though. Maybe someone could give some advice here. • Be prepared for the potential of large haemorrhage if you stuff it up. As the fistula has arterial communication the blood loss from a damaged fistula can be quite large. • Make sure the shunt is a functional one before attempting to access it. It is not uncommon for inactive shunts to be left in place. I have personally only ever heard of a fistula being accessed in pre hospital emergency situation once. It was a story reported to me of a pt who was trapped in a car with the only access available to the attending medical team being the lower half of an arm with an AV fistula. This was accessed prior to release of the compressive force in order to administer fluids, bicarb etc. However this pt unfortunately died at the scene. Hopefully not from a ruptured fistula. :oops: Hope this helps. Stay safe, Curse :evil:

Whilst I have agreed with most of your postings on this topic I do disagree with this particular statement. Just because you have “done it plenty of times” I don’t believe that should be your sole motivation for continuing this practice. Indeed I am sure it is not your sole motivation and was perhaps just the way it came across here. Having said that though there are some limited controlled trials that cardizem, when given concomitantly with beta blockers, is USUALLY well tolerated. I don’t like that word “usually” though and as such I would not have the balls to tempt this pre hospital. Indeed we have beta blockers as a documented contraindication to cardizem so the decision is out of my hands any way. In hospital I don't consider it an option because there are many alternatives. Although there are trials reporting concomitant use is of cardizem and beta blockers is usually OK, there are also reports of the combination causing profound hypotension with the added possibility of complete AV nodal block. As such I don't think it can be truly said that "there is no problem giving CCB's". Stay safe, Curse :evil:

Agree. Having read the posts I’m not sure who you think was suggesting that though. I just want to understand your stance on this topic. So if the pt had no contraindications and did clinically have a RVR would you then be happy to give the cardizem? Stay safe, Curse :evil:

To give or not to give? That is the question. Would I have given the cardizem? Well my answer to this is yes providing; • No history of WPW or obvious delta waves on the monitor. Mind you, at this rate you would have to be pretty good to see these. • Pt is not currently on beta blockers. I would be particularly suspicious in this pt given the history of AF and HTN. • Ventricular rate > 100bpm • Systolic BP > 100mmHg My main reason for using the cardizem whilst the pt is still relatively stable is to provide some ventricular rate control BEFORE the pt becomes hemodynamically unstable. I understand how some are reluctant to treat this pt in the setting of no current signs of rate related cardiovascular compromise. However my fear at not treating the ventricular rate EARLY would be that the pt would eventually become hemodynamically unstable. You then have the scenario of an unstable pt in a narrow complex tachycardia which may mandate attempts at synchronised cardioversion. Not ideal in someone who has not been appropriately anti coagulated beforehand. So I believe this is a case of treat early as the consequences of not treating will be much worse. Stay safe, Curse :evil: