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    Flightmedic, ED RN
  1. Hello al;, I am glad that was such a straight forward and simple scenario. In further investigation, you would find that the patient has indeed taken some Prochlorperazine that her mother had in the cabinet. I hope that I was acurately able to describe the symptoms of a dystonic reaction. And although the preferred treatment would be Cogentin utilizing Benadryl in the pre-hospital may be effective. Besides the medication I have listed above, what other medication(s) are out there that may have this effect on a patient? Also what does EPS stand for? Next week I will attempt to put forth
  2. Hello all here is weekly case #2. Hint - this weeks case will require some appropriate questions and investigation. On a separate note, there is not a possibility to obtain CEUs for case reviews without gaining approval number from every state. Case Presentation: 16 y/o female and her classmate leave school and drive to her house. During drive home, the patient states that she is starting to feel nauseous. Once arriving home the patient tells her friend that she has to use the bathroom for increased nausea and to see if her mom has any medication for nausea. Approximately 10 minu
  3. No D, in many countries, including the US (certain areas) you are allowed to initiate CPR/ACLS then terminate based on your local guildleines/protocols. For example when I became a paramedic in 1994, I rode wtih NY EMS (before it as FDNY), and the arrest alogo was cpr, intubate, defib if nec, EPI, IV Isuprel then if no ROSC... end attempts. Pull IV and ETT and leave patient. (I cant remember if medical control was contacted or not, sorry was a long time ago) This makes sense based on the pure volume of arrests that they probably work in a 24 hour period, the taxing of your ED(s) would be i
  4. I think we are all in agreement that as this case progressed, the decision making became increasingly difficult. I am always interested in others critical thinking on a patient who is truly an emergent one in the pre-hospital and hospital arena. I am grateful that I have had an opportunity to present a case that so many have been able to participate in, I hope that some have been able to take something from it. If people are still interested I will post another case on Sunday night. Is there any particular genre that people are interested in? medical vs trauma...adult vs pedi? Shoot me
  5. Yeah, I’ll agree this case presents many challenges. I would weigh the benefit for the patient to divert by looking at every clinical aspect that I was presented with -- airway, blood pressure, seizure activity and the ability to continue transport safely. I dont ever base my decisions on if I will be "called onto the carpet" as you put it, I base my critical thinking on what is placed in front of me. I am a firm believer that with the sickest patient, the more hands and minds available the better for the patient. Please don’t confuse how I state the reasons for diverting as if I do not und
  6. Sorry D, wasnt trying to not answer your question and it is valid. Personally, I will choose the most definative airway that I can place, usually RSI with oral ETT. My thoughts on airways adjuncts such as LMA, King etc is that they are secondary and although they have a place, they dont do well in transport (my personal experience and those of my peers etc) The LMA has great uses in the OR where gastric contents are usually known, and patients are being induced by an CRNA or an Anesthesiologist. I know there has been literature written about RSA with a known difficult airway and that may b
  7. Great post Asys, its hard to think or somethimes say outloud, but the fetus really is a secondary consideration with this case. Maternal well being = fetus well being period. Utilizing what medications most ALS unit have, starting Mg++ and benzos are your best route right now. Although I do suspect that most ALS units dont carry enough Mg++ to effectively cease her seizure activity. I also would quickly take the RSI path, hypoxia will be detrimental to both. My personal thoughts on community ED vs women/infants center is mixed, if I could successfully secure airway and begin ventilation,
  8. Interesting proposition. I would think that each provider would have to done his or her own airway assessment prior to begining tranport (i.e. Mallampatti, Lemon) and also go forward with their best clinical judgement. Personally, I consider LMA, surgical airway etc as second line in my difficult airway thought process.
  9. My biggest thought about administration of any paralytic whether a intermediate or long acting would be that it would (1) cease the physical seizure manifestation, but (2) would not discontinue the neuro seizure activity. I believe that I would administer a short acting (such as succinycholine) to obtain airways control though, taking into account the difference that a pregnant female presents for airway management: Airway, Oxygen and RSI To avoid fetal hypoxia, use high-flow oxygen. In compromised respiratory settings, pregnant women have an increased tendency toward rapid developmen
  10. Interesting about not carrying Mg++, any thoughts on why? I agree with Midazolam, Lorazepam etc. One question if you plan to secure airway in this patient, are you concerned about the use of paralytics and if so why would you be? And I totally agree with the decision to transport to a woman/infants hospital. Hey J again great points, inline with what Kiwi stated. For discussion purposes, lets say the patient's DTR were between 3-4, (3 - increased but normal, 4 - markedly hyperactive with clonus). Mg++ administration great idea, and I agree with agressive pain management an
  11. Hey Mike what program do you work for? Yes Labetolol is one of the first line drugs given in an OB case like this, some OB protocols are based on a 20, 40, 60 mg escalating dose until BP is under control. This is an interesting case in regards to what each EMS has available and how they are allowed to practice with it.. Resp depression and hyptotension two concerns, as well as DTRs Fantastic follow up questions, breath sounds, clear and equal excursion. No dyspnea/increased WOB other than noted from being in her gestational state. Edema as noted, no notcturnal dyspnea. Urine out
  12. WIthout giving much away and telling the end result, nice thoughts on the differentials, no rebound tenderness just generalized tenderness upon palpation.... Lets say that its a weather day (and RW is not flying) which hospital would you choose? FHT upon ausculatation in 130-140s...no Nausea/Vomiting/Diarrhea (N/V/D)
  13. Great start Mike and right on the money, although without a UA and protein etc its may just be considered PIH (pregnancy induced hypertension) First the tail number on that BK is N271NE... great thoughts on treatment, but most als systems in the US do not carry Labetolol or Hydralazine..what other choices do you think might be appropriate in this case? Nice thought on having Mag++ ready for administration...what are some of the side effect(s) that we would be careful to watch for during a 45 min GR transport? And yes BWH would be a great choice for care for this patient.... Very good
  14. There might be a way, I have to check on something. I know that some EMS web sites host CEUs for recert. Ill follow up and let you know.
  15. Hello all, after being inactive a few years from being in school, I find myself having more time and access to sitting down and reading for enjoyment. If people are interested I will post a weekly case scenario, that I have personally been involved in the care of, reviewed at M&M rounds or have gotten premission to present in this forum. Please dont think that by presenting cases I feel as though I have nothing to learn, I present so that I may have an opportunity to continue learning. That being said here is Case #1, I will attmept to present straight forward as well as complicated cas
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