AZCEP

BVMs aren't really optimal for use in neonates anyway. The flow-inflating (anesthesia) bags are better suited to neonates.

They will only inflate when the mask has an adequate seal, and will deliver oxygen when it doesn't have one. A self-inflating BVM will only deliver oxygen when it is being compressed.

1) In our city the nearest hospital is usually no longer than 10-15 minutes away

How does transport time relate to not treating pain? Unless you are doing all of your treatment enroute, you have time to relieve the pain. If you don't think you need to treat pain, then you don't need to have ALS providers either.

2) some cardiologists don't like it because it masks pain.

This is total, unadulterated CRAP. This philosophy has been widely disproven, and should not be used to limit pain relief options.

3) Old school medics don't like change and are stringent MSO4 fans.

If they don't like change they should get out of medicine altogether. Morphine has been used for so long that people don't want to have to think about whether it is effective or not. Fentanyl is a much better drug for this effect, and a good many places are already using it as an alternative rather than a replacement.

You are using a wider definition than you should be on this. Adenosine is very helpful for re-entrant tachycardias, just not the ones associated with pre-excitation.

WPW and LGL use accessory pathways to conduct the atrial impulses. Most of the tachycardia management options slow conduction through the atrioventricular nodal tissue, worsening the tachycardia through the accessory pathways.

Adenosine, calcium channel blockers, beta blockers-to a lesser extent all slow conduction through the AV node. Cardioversion is the best option if it is needed. Many times you will be able to monitor the patient, and not HAVE to do anything specifically.

So if flushing of the toxins out is key, would lasix be indicated?

Flushing the toxins is not "key", but maintaining kidney function is. With all of the electrolyte abnormalities that will be present adding a diuretic would be troublesome.

Treatment will depend entirely on how long they are entrapped, and the amount of force that is applied.

Cardiac monitoring will clue you in to the possibility of cellular destruction and the resulting hyperkalemia. If kidney function is maintained, fluid boluses will help to flush the nephrotoxic materials out some.

Rapid transport is key.

HHNS typically will have a much higher BGL than 560 mg% associated with it. There is still the little matter of the reduced respiratory rate that isn't being accounted for. HHNS won't usually cause a drop in the respiratory drive.

The tachycardia is a compensation for hypovolemia, not apnea. Hyperglycemia does not induce apnea without another cause being present.

I have had the distinct honor of initially missing a tension ptx in an ICU patient on a vent (with chest tubes in place bilaterally). Figured it out about 10 minutes into the code when the pre-code chest xray came back.

Just for the educational opportunity, how did this patient develop a tension pneumo with bilateral chest tubes in place?

Wouldn't the ventilator alarm a high pressure with this?

When you don't know, and the cause is unclear, I doubt there would be a problem with having someone immobilized. The additional imaging that will be needed would be a concern, but you have to consider the possibility of trauma.

Small cell lung CA causing an inhibition of water excretion

Two large bore IVs and a fluid bolus. Pupillary response?

Just to be clear, what the heck is "normal perforation"? I hope he's not perforated. That would indicate some pretty significant trauma. :shock:

Signs of trauma? Airway status? Breathing? Circulation?

Spinal precautions, OPA, begin ventilating, move to transport unit.

We have both Morphine and Fentanyl, just used Morphine as an example. Morphine is in an amp 10 mg/1ml, fentanyl is in an amp 100mcg/2ml.

I'd recommend drawing your fentanyl into 10 mL as well. That would give you 10 mcg/mL, just to make the math easier.

You don't draw up 10 more mL of fluid. That makes the concentration harder to figure out. Add 9 mL to your syringe, so the total volume is 10 mL to make a 1 mg/mL concentration.

It doesn't make it easier for the patient, but it does make it easier to see how much you are giving. I wouldn't recommend using a 1 mL syringe since it is so easy to lose some of the drug.

Since we have vascular access and his airway secured, I'd be hesitant to start messing with things too much.

Sodium bicarbonate could help with the hyponatremia, but it has to be infused pretty slowly. Another option would be hypertonic saline (3%) again with slow infusion rates. Keep him sedated, and manage seizures with BZDs, also manage the other electrolytes that will be off a bit.

Perhaps some mannitol?

SIADH?

Hyponatremic and a low BUN, eh?

CBC, and a chem panel

Do the lung sounds change after intubation? How about vascular access?

I'm also considering using an N95 mask. :wink:

Any nicotine patches on the patient?

He needs intubated as well.

If you see the late sign of tracheal deviation, it's amazing how fast it will straighten up after you do it.

I can only hope that people aren't waiting to see the trachea deviate before they decide to do something.

The same as it's action any other time you use it.

www.rxlist.com/cgi/generic/gluca.htm

For an epinephrine infusion:

1 mg/250 mL = 4mcg/mL

Run through 60 drop tubing at 2-20 mcg/min

Dopamine is a bit more complex, but not overly difficult.

400 mg/250 mL = 1600 mcg/mL

With this concentration and using 60 gtt tubing you will have a constant 26.67 mcg/gtt

Find the patient weight in kg.

Run the infusion at 2.5-20 mcg/kg/min

OR...

Use 10% of the pt weight in pounds to figure a 5 mcg/kg/min dose and titrate from there.

I hope I've gotten those right since it has been a while since I've had to think about them.

tPA will destroy all the clots that have formed indiscriminately. You don't know if there are any "good" clots present or not, so let's not just eliminate all of them.

Heparin reduces the formation of new clots, but does not break established clots down.

Who gives a rat's hind parts about passion.

I want someone that is knowledgable enough to know when they don't know enough. Passion has nothing to do with it. When you reduce a profession to the emotion it shouldn't take to begin with, you cheapen everyone involved.

Increasing demands are part of the job. If you don't mind it, then why are you questioning the need for it?

Is it too much to ask to use proper grammar in your paragraphs? :roll:

Just to keep things current, all of the terms being thrown around here are obsolete. The new term, recognized by international consenus, is drowning and then has modifiers such as death, with morbidity or without morbidity. Here is a link to the paper from the international body.

Maybe I'm just being simple, but how do you have death without morbidity?

Or why categorize something as with morbidity when that should mean death, right?