NR_Paramedic

regarding the life to NTG...its also very short acting...nitroprusside is great...but if you dont have it use the next best thing...may be the NTG or MS....obviously doesnt hurt to consult a doc if you have questions...(try to see what they have to say when you talk to your med-com doc.)....I'll ask mine and see what he has to say... Conrad

CPAP def. to lead off, as far as the failure treat what will kill them first, the left sided failure. As far as the A-fib goes dont assume the beta agonist caused it. If the rate is high enough to cause the failure then maybe that is the underlying cause....the telltale sign there would be hypertensive vs. hypotensive....Also the ASA is not a bad idea and for sure will not hurt this pt. the pt is not circulating a whole lot of blood (therefore peripheral edema)....great time for clots to form...esp. w/ the a-fib. Also w/ the NTG, personnaly I would give it and not worry about the "right sided MI"...however in this case I would make sure that I had an IV est. prior to NTG admin. if the pt. became hypotensive then I would elevate the legs, drop the head and administer a 1-200 cc bolus monitor the pt. I would def. give the lasix, and lots of it....we do double the daily dose in my system...(most I have ever given was 200 mg...however that pt. could have gotten 480 mg per protocol). One more thing I didnt see anyone mention which suprises me is MS04, morphine works excellent for CHF pts. (esp. for those w/ renal failure where lasix may not work as well)...just consider that this pt. needs the preload reduced...you can scare yourself into not treating this pt. by thinking to much. Don't get me wrong, you need to consider the ramifications of your treatment...however...you also need to treat what will kill them first...and in this case it is left sided failure. But remember the underlying cause (a-fib etc...)...maybe treating according the CHF/Pulm. Ed. protocol is wrong, maybe the arrythmia protocol is the way to go. anyway...just my thoughts...g'night and good luck.... Conrad

The whole problem with this argument is that class 1 pts. (trauma excluded) MUST go to the closest ER, if you pass 2 community ER's w/ a pt. having an active MI and the pt. dies before you get the cath. lab hosp. then you are liable b/c the community ER can still administer thrombolytics etc... Most systems that I am aware of do not have protocols saying that stroke pts. go to stroke centers, cardiac pts. go to cardiac centers etc...I believe they should be in place but they are not. Guess that keeps the SCT/CCT guys in business. The Idea that a paramedic can be liable for taking a class 1 pt. to the closest ER is scary. Esp. for more suburban or borderline rural EMS systems where its not a 2 min. difference. If they want to sue anyone they should sue whoever wrote the protocols. The paramedic just has to follow his standing orders.

The reality is that it is better to circulate blood w/ 50 % 02 sat. than it is to have stagnant blood w/ 100 % 02 sat. You need to build up the pulmonary pressures and hopefully get enough blood through the heart so that the electrical system can maintain a workable arrythmia (fib, tach etc...)