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DartmouthDave last won the day on April 19 2014

DartmouthDave had the most liked content!

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  1. Infusing Blood

    Hello, I liked the blood set for the Medsystem III. It is quite helpful when giving lots of blood. Sorry, I am not following you 100%. I think you are suggesting connecting a gravity blood set to the half-set (the one you connect the syringe to). If so, where I work we do that from time to time. No issues at all. Just not as tidy. All the best, David
  2. second line seizure medications

    Hello, I have attached a YouTube link showing the challenges of a status patient in the field (starts around the 2:15 mark). Interesting stuff. All the best, David
  3. second line seizure medications

    Hello, I agree Matt, outside the hospital, things are more worrisome with many unknown factors. In fact, in most cases, the etiology of the seizures is unknown and airway protection is a great idea. Especially, in the case of a TBI, SAH, and so forth. As opposed to a 'neurology' consult with a chart and background information. In fact, many difficult to manage seizure patients (if local) are know by the neurology service. I was referring to the approach outlined by the authors and not critiquing ED seizure management at all. Again, it is better to have a secured airway in most situations. Cheers
  4. second line seizure medications

    Hello, I have attached a link to a outstanding review article from BRAIN: JOURNAL OF NEUROLOGY on the management of status epilepticus. Very helpful information. Also, if you look at their step approach they are much more cautious than one typically see in emergency medicine (i.e. three+ seizures without recovery is status). More time is given for medications to work before intubation and general anesthesia. The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol http://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/brain/134/10/10.1093/brain/awr215/2/awr215.pdf?Expires=1485878433&Signature=EYWaFW2VPwjf75aa7W90l-zxtW~X2vCN5dh0wnuXw1SgIo7wor2U3CZ75HwaPiUX5QyfF4uN0tzJlVUFYsGtr8XelQ5JbPfy7l55Gz~xqy1TXE4g1lap8KQjNGicehxghlAq6P3BP0jQ22ZD-lJnaCLJt8nxTMDMDrAvBnbrs5I72AhtoFQs8cTFuHcgCNmgTROXIpUf9FnxJfZMtnNU6raI3gl1HB2BVGYrlFeX6gZZze3Wthk~cuQqSoQTCAPMegLPzQIR9MnGXXyc2OWA~a6IwbC2dKBywvIbnQ-V8EMCK7sh0CEa~ovWSosPHINRPHgnOTn4CutQfd0LLjhz4A__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q
  5. Mechanical CPR to ECMO to ROSC

    Hello, I have been with Medavie for the past 5 years now. Sometimes, I still miss the great white North. K
  6. Mechanical CPR to ECMO to ROSC

    Hello, Very interesting. In my region, as far I know, ECMO has not been used for out-of-hospital cardiac arrests. Off Label, in the case with the young women and the PE, did they try fibrinolysis first? Cheers
  7. Ketamine and Trismus

    Hello, I know that Ketamine sometimes causes non-purposeful movements and hyperreflexia. But, I have seen two burn patients (one electrocution and the other was spilled gas on a fire) that have had prolonged trismus when Ketamine was used as an induction agent. Needless to say, it cause some moments of anxiety. I have looked at Micromedex (a pharm database at work), spoke with a Pharmacist and checked a few other sources but nothing conclusive. However, it is odd that it happened so profoundly, twice, with two different burn patients. Has anybody had issues with trismus and Ketamine? Thank you, David
  8. Evidenced Based Care Protocols

    Hello, Any other good place to start is checking out the local hospitals care bundles or packages. For example, the hypothermia protocol. Sepsis protocol. Sedation protocol. etc........ Plus, it is nice when the pre-hospital and the hospital are on the same page. I would also read the Barr article on the current evidence on sedation, agitation, and delirium. http://www.ncbi.nlm.nih.gov/pubmed/23269131 And, the new surviving sepsis 2012 guidelines; http://www.sccm.org/Documents/SSC-Guidelines.pdf Lastly, as I ramble on, the AIME textbook is a nice resource for airway protocols; http://www.amazon.ca/Airway-Management-Emergencies-George-Kovacs/dp/0071470050 Oh...wait. The CRASH2 study for TXA in trauma patients. Cheers David
  9. Drugs for agitated patients?

    What do you take?
  10. Drugs for agitated patients?

    Hello, Excelelnt discussion. Back to Swe112 comments on Propofol and the agitated patient. It use is gaining popularity for non-intubated patients with delerium and agitation. Typically, a low dose infusion is hung until standard PO medications have time to take effect (Clonadine/Seraquil ect...) In fact, are published case now of low dose Propofol used in palative acre as well. However, as most poster here will quickly point out this can not be generalized to the pre-hospital environment. But, what is interesting is the use of Propofol in transporting (fixed wing/HEMS) psychotic patients to Regional Medical Centers from small communities. As well as Ketamine gtts. Dr. Minh Le Cong blog has lots of good information on it. There was even a case of a very dangerious psychotic patient (in New Zealand) that was sedated with Remifentinal/Ketamine and the inserted an LAM and connected it to a t-piece. Interesting stuff. We covered this in great depth at my service recently. I just wish I had a copy of the power point to put up. We tried a Propofol gtts once for an non-intubated agitated patient. It worked well. However, in the end, we have decidied to go with standard therapy (Haldol/Zyprexa/Benzo) because the services in these case studies are Physician based and can not be generalized to a non-physician based team. Cheers, My rambling post in done.....too many Starbucks coffee today! http://prehospitalmed.com/about/
  11. Upper GI Bleeding and Octreotide

    Hello, I have used Octreotide in the emergency management of bleeding gastroesophageal varices in patients with cirrhosis. However, I just transfer a patient with upper GI bleeding (throat and nose) from cancer (not sure of type). He was on a Panto gtts and an Octreotide gtts. There was no history of cirrhosis. I am not sure if the Ocreotide was indicated? I was wondering if other have had expereince with this situation? Cheers
  12. I:E and Peak Pressure (PIP)

    Hello, A quick question for those in the know. With volume-cycled ventilation a shorter I-time means an increased flow rate and in turn an increased peak pressures. Is this increased peak pressure just due to the resistance of the ET and the circuit? Or, is this increased pressure transmitted to the lung? Cheers
  13. Hello, I agree and disagree with you RM. Yes, identification and early goal direct therapy for sepsis improves outcomes. But, this could be achieved simply training Paramedic look for the SIRS/Sepsis criteria (low temp, high temp, high resp, high heart rate, low BP) as outlined in Surviving Sepsis. In fact, the last ED I worked at triage looked for patients that meet the SIRS/Sepsis criteria and would call a 'Code Sepsis' to ensure a rapid and efficient treatment. It was very effective and did not require the use of expensive point of care testing for lactate. Thank you,
  14. Hello, Would a lactate level change the treatment a great deal? Would the cost be worth it? A lactate can be elevated by many things. Don't get me wrong. I like the gadgets. But, I don't see its utility for a short transport times. Cheers
  15. antibiotics

    Hello, I have had limited experience with burn patients and only one of these was during the acute phase. He was transfer to a burn center at a large teaching hospital and they didn't want prophylactic abx given. Second, I think the cost would be an issue. Most of the abx carried would expire before being used since (lucky) critical burns are not that common. Cheers....