AZCEP

That's a pretty good stab mobey, but the onset of Amiodarone is so long that the VT will continue until it takes effect. Recurrent/refractory VT. Treatment nuances will depend on historical factors. I'd consider some magnesium since the lidocaine is ineffective, but I need more information before deciding.

1. Preparation --This step is much more important than for the laryngoscope assisted intubation. The patient and your equipment needs to be prepared so that you do not have to think about where your equipment is, or what is happening with the patient 2. Topicalization of the nasopharynx is quite helpful, but not mandatory. Some benzocaine is nice, and many will get by with some Neosynephrine, but most can be done with a little KY jelly. 3. A premedication regimen of Lidocaine/BZD/narcotic of choice is also very helpful. Because of the increased trauma that is caused, using these agents can prevent problems once the tube is placed. Use just enough to reduce the CNS response, and not so much to obliterate the respiratory drive. 4. An Endotrol tube that is properly sized, and a BAAM whistle should be mandatory equipment. The combination makes it near impossible to miss. Waveform capnography can also be used to place the tube, and should be prepared for verification once it is. 5. Introduce the tube into the nares aiming straight back. DO NOT aim to the roof of the nasal cavity. This only causes increased resistance and a greater chance of lacerating a turbinate. 6. Advance the tube to the posterior nasopharynx. Preparation for the angle will allow you to begin to curve the tube to avoid the richly innervated area that will be met. You should be advancing rather slowly at this point, so once you meet resistance some side to side rotation of the tube can assist in passing it. 7. Advance to the level of the glottis while carefully listening. The whistle should become louder as you get closer to the opening. 8. Wait for an exhalation, and pass the tube on inhalation. There will still be air moving through the whistle as you pass it, but it will become audibly louder on the exhalation. 9. Confirm placement with your capnography. Inflate the distal cuff until resistance is met. This can be very subtle so inflate a bit slower than you think you should. You only need to seal the air from around the tube. 10. Secure the tube and begin ventilations. 11. Consider further sedation measures. [NOTE: These are the steps I have used to successfully nasally intubate, and there are many other ways to perform the procedure. Your mileage may vary.]

Treatment is going to depend on how far the disease, and specifically the inflammation has progressed. Corticosteroids are the common first step, but if they fail to control the inflammatory process, there are a number of possibilities that can be tried geared toward slowing down the inflammation in the respiratory system. AKA Acute Febrile Neutrophilic Dermatosis, more common in middle aged women and associated with a number of medications and other diseases. Presents with a fever, and acute onset of erythematous plaques, nodules, and occasionally pustules, assymetrically distributed over the face, neck, and extremities. No, I had never heard of it before. What is the Barr body, and why is it important?

I'm with P3medic on this one. The heart is as stable as we can probably hope for with the rest of the situation factored in. Pushing more chemicals isn't going to be of benefit, and might make things worse. If you have Fentanyl available, it might be a better choice than morphine for pain control, but if not use what you have, obviously.

It can also reduce the bronchoconstriction in the larger airways. Combined with the reduction in bronchial secretions, I guess it makes sense. With the amount of PNS innervation in the upper airway, using it sublingual could make things a bit easier. First I've heard of it this way though.

I'd like to add that the patient with pulmonary edema due to heart failure can usually tolerate a moderate amount of fluid replacement. It isn't because of a loss of volume, rather their volume is in the wrong place--a relative hypovolemia. This is especially useful when using nitrates, or for the right sided failure situation. The typical prehospital dosing of NTG makes it difficult to control, however with the symptoms being present NTG is still indicated. It is not uncommon to use the nitrates with a pressor to improve the hemodynamics. Again not something that is often considered by EMS.

Nope, not forgetting that just sidestepping the issue of "guts". Poor form to bring it up when talking about this particular procedure.

The infant may well be viable for a NICU team that is well versed in managing this type of situation, but in the prehospital environment with the limitations of equipment and manpower we are placed in a less than optimal setting with a critically unstable patient that has undergone a prolonged period of hypoperfusion. The current literature supports the application of the procedure if initiated within 4 minutes of the mother's cardiac arrest. If you don't know what the down time is you do not perform it. I'd love to hear from any non-military agencies that follow this guideline.

The scope of practice for the DOT curriculum educated paramedic does not include post mortem C-sections. The situation does not determine if it is acceptable or not. True enough the procedure is not all that difficult, but that is a moot consideration when you step that far outside your scope. Something that seems to have been missed in this discussion is the little matter of the infant's survivability. Unless you are working on mom prior to her arresting, and are able to determine precisely when she does, there is no way that you will have a viable patient once you get done talking through the procedure and performing it. The pathology demands that the infant is removed at the first sign of maternal distress, not after she has checked out. Once that happens how long has junior been without oxygen, or adequate perfusion for that matter?

Basically, it's a fancy term for sharp and dull sensation. You take a paperclip and open it up so you have two pointy and one dull end. Then you start poking around until the patient can tell the two apart. There is ton more to the testing, but this works in a pinch. It will tell you the degree of nerve involvement, and the level it starts/stops.

What kind of work does he do? Pulses in all extremities? Cap refill? Temp.? Vital signs? Point discrimination in the effected limb?

Boy, those doctors know everything don't they? I seem to recall that AIVR is (was) very common during the time that tPA was the treatment of choice for MI. Reperfusion dysrythmia was the terminology that was floating around at the time. For this situation, I'd be inclined to treat the discomfort with some oxygen and consider some fentanyl/morphine. Using NTG is a good thought, but since it hasn't been very effective moving past it might be warranted. The lidocaine/amiodarone debate is pretty interesting as well. Without a beta blocker available, amiodarone is the closest you have. That doesn't make it right, just limits the choices you have to make. Remember the ventricles are assuming control of the rate because the SA isn't going fast enough to provide them with what they need. Lidocaine might do the job of reducing the irritable foci just fine, and allow the SA to maintain control. Amiodarone will probably allow for the same mechanism, but tends to take quite a bit longer to take effect.

Even at $3500 they are getting bilked. The CC where I used to be had paramedic classes for that. Kind of makes you wonder how much overhead they are trying to support. Can we guess that the money isn't being completely reinvested in the training program?

The students should have been questioned about what they understand about the experience, but using the physical to reinforce the imaginative is a useful tool. For a thirteen year old to truly understand some degree of training might be useful. You can talk about the experience all day long, but until you are in the situation you can't truly understand it. I wonder if it would have been acceptable to bind some of the white kids. Would the NAACP have a problem with that, or would they even get involved at that point. The sensitivity of the students is to be expected, but do we really believe that long-term harm has been done by a ten minute exercise? I am curious what direction the history class will go for the Holocaust, or the discussion of Russia under Stalin though. :shock:

Take a deep breath, hold your nose, and jump in. Just like with swimming, you are going to have to get your feet wet sometime, and the sooner you do the more comfortable you will become. The first step is to check your own pulse. Once that is handled, then you can worry about everyone else. Make sure that you can go home at the end of the shift with the same number of parts in the places they are supposed to be. It is not your emergency, no matter what you may think the patients will not give it to you because you are a kind face. Absolutely continue your education beyond what your employer requires.

The secretions are the patient's only defense against the intrusion. I don't think I'd want to take it away from them. The epi might be a consideration, though I'd probably consider racemic first. The soft tissue swelling would be a real problem, and should probably treat it as a burn of the oro-/laryngopharynx.

The words are coming from a medical director that shoud be able to choose the correct terminology when he is discussing the issue with the media. We've managed to muddy everything else about EMS over the years and now our medical direction is further damaging the perception.

The good doctor wants to be viewed as looking out for his community, but he is "training" his providers rather than providing the education they most definitely need. As long as the "standards" are held to the lowest common denominator, there will never be any advancement of the craft.

The discussion is a good one to have, but you might want to find out what your protocol allows first. Your dosing is reasonable, but you won't be delivering enough medication with the mix you have outlined. AHA actually included an epinephrine infusion for cardiac arrest mix in the ACLS Principles and Practice book in 2004(?) Take 30 mL out of a 250 mL bag of NS Add 30 mg of 1:1000 epinephrine Run the infusion at 17-20 gtt/min with 10 gtt/mL tubing until ROSC or efforts are terminated The amount delivered is roughly the same as you will give using the more typical adminstration of 1 mg of 1:10 000 every 3-5 minutes. This is especially useful for prolonged transports or when you have fewer providers to help with the work. You also have to be very careful with the use of the IV site for anything besides the epinephrine. Atropine shouldn't cause a problem, but Amiodarone and NaHCO3 tend to make the line garbage when mixed with epi.

Time for a fasciotomy or three. Compartment syndrome is going to destroy our ability to ventilate, and his ability to perfuse.

Yep, the LMA FastTrach is pretty slick. As for the "Difficult Airway" set, it is probably a box full of equipment that no one ever thinks about getting until they trip over it, or need to use it as a step stool. www.theairwaysite.com has some recommendations as to what should be included in one, if you are interested. It really doesn't have anything that you shouldn't have readily at hand, EMS wise though.

Unfortunately, that is precisely what Brethine will do. It doesn't have as much of an effect on the PVR, but it will still increase the MVO2 through it's beta stimulation. It is less drastic than epinephrine, but for the patient that you are considering it for epinephrine isn't going to work very well either. Dilating bronchial smooth muscle when the alveoli are collapsed doesn't usually help much. CPAP/BiPAP is a much better option.

The addition of fluid to a compromised container is not going to be much help. Sure, running some fluids in then reassessing is a reasonable thing to do, and that should have been the stance the good Dr. took. Unfortunately you are working under his rules, and there will be more than a few instances where you walk out of a meeting scratching your head about what you were just told. If you would like details, PM away.

Going over the head of this particular agency's supervisory staff will not do anything to help the problem. Even if you get the prehospital coordinator on your side, everything will end up back in your lap when word gets back to the station, and you can bet that it will beat you there by a few minutes. I've made my suggestions as how to handle this situation, and I hope things are working their way out for you Kaisu.

As a lifelong Dallas Cowboys fan, I cannot in good conscience, allow any decision to be based on the ability of the Washington Redskins. I would much prefer the candidates home state/town team be allowed to participate though.