DartmouthDave

Hello, Edit: In my last post I should have said a RBB with a hemiblock. The left side has two pathways while the left has only one. LOL....this supports my point that I need to work on my cardiac more. With a history of HTN and DM maybe the patient has started to develop some renal insufficiency as well. Could explain the elevated potassium as well. Cheers

Hello, If the fellow is a wild man I think (despite the wait) the IM/IN would be a better options than fighting for an IV. Get the IV once he has settled for a follow up dose if needed. Better than getting a stuck while fighting with an angry drunk. IMHO. Cheers

Hello, A very interesting thread. Next, we should tackle IIb/IIIa Inhibitors. Cheers... BTW...excellent post DP

Hello, Hypothermic patients can go in to Ventricular Tachycardia (VT) if moved too aggressively. However, this isn't too common in my somewhat related expereince. A certain cohort of patients who code are started on a 'Hypothermia Protocol'. With the goal of decreasing their core body tempature to 32-34C in 4 hours or less. Now, this is a rapid freeze and the most common problem was Sinus Bradycardia (30-40's). Second, hypotension typically isn't an issue due to the vasoconstriction. When I worked up North we had a reasonable number of mild to moderate hyopthermia patients as well (34-35C) and the most common problems were bradycaria and pain (when rewarming). Cheers.... Time to race to work!

Hello, If this fellow has had two AMI maybe he had a intermittent hemiblock? I saw a patient once that had a LBBB and an anterior hemiblock. He would get brady from time to time when he blocked his posterior pathway. That is my shot in the dark. CCU stuff isn't my strongest point. Now, some would argue that Atropine won't work on anything below the AV node. But, I have seen Atropine work times that one would not suspect. Have to run....my friend and his two children have arrived. All hell is breaking lose!!!

Nello BoCat9, You take a close look at the patients and find a negative Holman's Sign. You speak with the nurse and review the patient flow sheet and it appears that the has been a gradual decline in the patient's LOC and respiratory status post operative. Not a rapid change. You and MedicRN suggested some Flumazenil. For the sake of argument it isn't available. Cheers

Hello MedicRN, For the sake of the scenario this small community dose not have an ICU. Reasonable position on refusal of transfer due to the patient's condition as well. But, lets just say your team has to run with it. =) You speak with the Nursing staff. The order was Valium 5-10mg IV PRN for withdrawal. Which, has lead to this patient receiving a massive 600mg. You suction thick secretions from the back of the airway and the gurgling is gone, for now. Cheers

Hello, You are dispatched for a STAT transfer from a small community hospital to the local University Hospital for a ICU consult. Transport time is 30-40 minutes. The reason for the transfer is a post-op NSTEMI. The patient is a 62 year-old male with a history of smoking (1 pack x 40 years), ETOH (daily), HTN, DM, Dyslipemia, angina and depression. Mr. Smith fell (while drunk) and fractured his right patella. He was admitted under Surgery three days ago. On day 2 he had ORIF was done and his right leg placed in a orthopedic brace. That evening he started to show signs and symptoms of ETOH withdrawal and was started on Valium IV PRN. The nurse states that by the evening of day three the patient's clinical condition worsened with a decreasing LOC, BP, Spo2 as well as a positive Troponin. Prior to this the patient was very agitated and violent. Trying to punch and hit staff. Trying to climb out of bed. Pulled out numerous IV and his foley cath as well. Large dose of Valium have failed to settle the patient (in total 600mg of IV Valium have been given over the last 48 hours or so). He is to be transfer for a CCU consult for a NSTEMI. He VS, labs, xray, medications are as follows: GCS: 7/15 (E1 V2 M5) Pupils: 3mm + Reactive Motor: Strong x 3 (right leg is in a brace) HR: NSR with long OT, numerous PVC and ST depressions BP: 100/52 Temp: 38.5 Resp: 32-38 Increased WOB and gurgling in back of airway SpO2: 86-87% on FiO2 100% (high flow system) Lungs: wheezing and course crackles (gurgling in back of throat) Na 140 K 3.0 Hg 102 Mg .8 Tn .08 BGL 15.8 ABG (ph/o2/co2/be) is 7.1/60/70/-11 CXR shows pulmonary edema Med are ASA 81mg, Plavix 300mg, Enoxaparin 80mg, Nicoderm Patch 21mg, Synthroid 0.05mg, Valium PRN (total dose 600mg IV) He has one 20G IV with NS+20KCK @ 50cc/hr Cheers...

Hello, It seems that this 'intergration' has gotten of to a bad start. One thing I know for sure is cash strapped health authorities will try to push the envelope with patient to staff ratios, and staffing mix in order to save cash. If done for the right reasons (i.e. not as work relief and as ad hoc staffing)medics in the hospital can be very benificial. Change can be difficult. But, worth the trouble. Here are two example that I know of as an excellent application of ACP in the hsopiatl setting. ---> Capital Health District (Halifax) uses ACP as triage at the QEII ---> The Cobequid Health Center in Sackville (NS) uses ACP for casting, sutures and as a part of the code team. Cheers

Hello, Nice case study. I will take a shot here: The cool, hypoglycemic, hypotensive patient that has been feeling unwell for a week or so could be Septic. But the waxy skin dose not fit. The waxy skin is what makes me lean to the thyroid. Endocrine is my weak point so bear with me here. I am thinking hypothyroidism that has worsened in to Myxedema Coma. Myxedmea is a state of decompensated hypothyroidism caused by a stressful event....in this case a long period of illness. I have seen one Myexedma Coma a few years back. Fits this bill...kind of. It was a medical ward patient whose levothyroxin had 'fallen' off the MAR. It could be her medications ----> vigamox, PCN, phenergan, levothyroxine, maxzide, zestril, flexeril, fioricet, asa, premerin, zocor. I don't know much about the ones in BOLD......so I am going to research them some. Have to run... Cheers....

Hello, Yes, the lungs are clear other than a few crackes (smokers lungs). You were 100% with the embolism. However, in this case it is Fat Embolism Syndrome. I based this scenario on an unassuming female patient with a few fractures who crashed hard after a couple of hours in the ED. She was tubed and even then had oxygenation issues for quite awhile. Cheers

Hello Mobey, The patient is placed on a NRB and the sats don't perk up. Around 86-87%. Also, the patient is becoming more agitated and restless. A 12-lead shows Sinus Tachycardia (sorry I don't have a scanned copy). The pain was sudden onset and described as heavy and it hurt to breathe. Currently, the patient is too confused to give more information. Lastly, you are on the right track with a PE. However, there is an other pathology going on here. Cheers

Hello, Lets gets things moving. So, the hospital gives some KCL, Mg and a little fluid and you are on the road to the University Hospital. Once you are 40 minutes outside of town the patient starts to complain of sudden onset shortness of breath and mild chest pain. VS are as follows: GCS 15 BP 170|110 RR 32 SpO2 88% on NP at 2 lpm EKG: Sinus Tachycardia at 130 Cheers

Hello, Good points. Here are some labs that are available currently: CBC: WBC 12 Hgb 92 Coags: INR 1.5 PTT 40 Platelets 250 Lytes: K 3.0 Na 145 Mg .97 Cr + BUN is slightly elevated.....can't think of the scale right now So, she is anemic, and has a low K and Mg. Plus, seems a little dry due to the elevated Cr/BUN. She had various x-rays done. A FAST (ultra-sound) showed no internal injuries. So far so good. This scenario is based on a patient that was admitted to a hospital I worked at. Lots of good learning points in what could be seen as 'just' a transfer. Cheers PS....lol Looks like Mobey posted while I was typing!

Cheers............. Hello, Dead on. This lady states that her last drink has been almost 48 hours ago. She states that she was trying to quit drinking because it has been destroying her life. She dose not think she is DT because she is too young. Old old drunks get that!!! She is tachy, diaphoretic, anxious and has faint tremors in her hands. Occasionally she picks at the Iv lines, ekg leads and foley. So, what would be choice in managing this? Cheers

Hello, You are an ALS crew in a small town. The local hospital needs you to transfer a patient to the local university hospital for a surgery consult. The patient is a 22 year-old women that was struck by a car going 30km/h. She suffered a fractured left tib/fin, pulmonary contusion and a fractured right wrist. The patient has a five year history of ETOH abuse. In addition, she is a 1-2 pack a day smoker for the past 5 years as well. The patient is on no medications. Upon arrival the patient is pain free. But feels nauseated and anxious. She is fidgiting with her IV sites. She has been given Morphine for pain. C-spine is clear. Her VS are: GCS 15 BP 150/90 HR 110 EKG Sinus Tachycardia Temp 37.5 Spo2 92% on room air Lungs: fine crackles and a smokers cough Ok.....the road trip is three hours. Anything before you hit the road? Cheers A slab is on the leg and arm.

Hello, From my point of view it seems like an awkward system to have the FD arrive start treatment and they had over transport to a 3rd party such as AMR. How dose this work? Dose the FD medic go with the AMR crew all the time, sometimes or never? I think a call could get congested. There could be a log jam of fire trucks and ambulances at each call. What dose the FD respond in? An ambulance? A Fire Truck? Chase Car? How many people? A full crew of four fire fighters? Also, the AMR crew may not agree with the treatment rendered. But, despite this you have to haul them to the ED. Or, catch flack if things went poorly. Lastly, I think, it would be sweet deal for the FD. Respond. Treat. Leave. While (for most calls I assume) the AMR crew drives to the ED, dealing with triage and possible sits and waits for a bed. IMHO. Cheers

Hello, Here is the interesting part. For some unknown reason the patient had developed a thoracic aortic aneurysm (TAA) that started at the aortic arch. A CXR was done and the cardiac silhouette was enlarged. A CT/Angio showed a TAA that started just above the aortic valve and well passed the aortic arch. It was also leaking and had numerous hematomas. The pain was from compression of various nerves within the chest. The abdominal pain was from a compromised blood supply to the gut. As it was explained to me the hematomas and expanding aneurysm can actually reduce the lumen of the aorta itself. I wish I had some follow up. This is a case that I saw quite awhile back when I was quite new. Still, interesting. Cheers

Hello, Here is an other odd one that I saw awhile back. Case#2: EMS is dispatched to a local baseball game for a 18 year-old male that is complaining of chest, back, flank and abdominal pain. Upon arrival they find the patient laying on the gorund in 10/10 pain that is described both as 'sharp' and 'dull and aching' in nature. The pain has been getting worse over the last few days with a dramatic worsening of the pain in the last 15 minutes. The patient also feels quite nauseated and has had two episodes emesis. The patient has no medical history. Dose not take medications. Nor, dose he drink or take any illegal drugs. The patient's skin is pale and diaphoretic. He is alert and orientated. His VS are: HR 120 BP 79/50 Resp 28 SpO2 99% Radial Pulse: weak EKG: A 15-lead EKG is done and it shows ST elevation in V4R and V5R with Sinus Tachycardia The crew starts IVx2 and give a 1L NS with a slight rise in BP and slight drop in HR. So, what the heck could be causing this much pain and an isolated right-sided MI in a health 18 year-old male?? Have to run. Mulling it over.... Cheers

Hello, 1 in 6 calls. I agree that sounds suspect. Sure, who funded the study........... I wonder. Next, we will see JEMS awash with glossy add for ultra sound machines. Cheers

Hello, Sorry, been away for awhile. Sold my house and have one new job and maybe a HEMS gig (very anxious). Fiznat, It was a hard call for the crew. The patient was in a great deal of pain and they felt that it was worsening his clinical condition. Alas, Morphine was the only drug they had available. I have read about Ketamine in pre-hospital pain control as well as Fentanyl. Better drug, I think, if available. Quickfire wrote: As for SIRS, why was his HR so low with a BP like that? From what I understand (which probably isnt much) He should have been getting tachy, as a compensatory response to the hypovolemia. Was there something else found to account for this? Or was he previously borderline hypotensive and possibly tolerated it better. I agree. I was very weird. Nor dose this patients clinical picture mesh with any clinical description of SIRS that I have read. One theory was a mild cardiac contusion (despite a normal look cardiac echo, negative troponins). Who knows?!? Chbare, Could be. The fellow wasn't the best at recalling medication he was one. Cheers.... PS... If anybody has other weird but true case please feel free! Hello, Sorry, been away for awhile. Sold my house and have one new job and maybe a HEMS gig (very anxious). Fiznat, It was a hard call for the crew. The patient was in a great deal of pain and they felt that it was worsening his clinical condition. Alas, Morphine was the only drug they had available. I have read about Ketamine in pre-hospital pain control as well as Fentanyl. Better drug, I think, if available. Quickfire wrote: As for SIRS, why was his HR so low with a BP like that? From what I understand (which probably isnt much) He should have been getting tachy, as a compensatory response to the hypovolemia. Was there something else found to account for this? Or was he previously borderline hypotensive and possibly tolerated it better. I agree. I was very weird. Nor dose this patients clinical picture mesh with any clinical description of SIRS that I have read. One theory was a mild cardiac contusion (despite a normal look cardiac echo, negative troponins). Who knows?!? Chbare, Could be. The fellow wasn't the best at recalling medication he was one. Cheers.... PS... If anybody has other weird but true case please feel free!

Hello, DawyneEMTP & Mobey: The Gravol is a local thing that ALS dose around here. Not sure why. The theory was the immune/inflammatory was due to trauma not infection (as noted by chbare). Here is a defination of SIRS from Up-To-Date: Systemic inflammatory response syndrome (SIRS) — SIRS refers to the consequences of a dysregulated host inflammatory response. It is clinically recognized by the presence of two or more of the following (table 1): •Temperature >38.5ºC or <35ºC •Heart rate >90 beats/min •Respiratory rate >20 breaths/min or PaCO2 <32 mmHg •WBC >12,000 cells/mm3, <4000 cells/mm3, or >10 percent immature (band) forms SIRS can result from a variety of conditions, such as autoimmune disorders, pancreatitis, vasculitis, thromboembolism, burns, or surgery P3Medic: Good point. No steroids were given or labs done at the time he arrived in the ED. It could be an other possibilty or contributing factor. Adrenal insufficiency is often overlooked. I didn't look to see if steriods were added once he left the ICU/ED. It was very odd. The fellow wallked out of the hospital a week or so later. In fact, he left with boardline hypertension! Cheers

Hello, I hope this the right section. I thought that this may be a good area to present unique cases for all the members of the form to learn from. CASE: A 52 year-old male was riding a motor bike accross North America. Traffic ahead was breaking and he was caught by surprise. He applied the breakes and the bike torqued to the side and threw the drive in to on coming traffic. He slid along the ground and was clipped by a small car a tossed in to the ditch. EMS arrive shortly. He was lucid (GCS 15)with no deficits (strong x 4). He c/o right sided chest pain (# ribs) and left arm pain (humerus #). His VS were: HR 80 EKG - NSR BP 70/28 Resp 20 SpO2 99% EMS called a trauma alert and insert IV x2, gave 1L NS, and Morphine and Gravol IV. Upon arrival to the ED a full trauma work up was done (FAST, CT, XRAY). No source of bleeding was noted. However, despite this the patient remained hypotensive despite fluid challenges. In fact, a central line was inserted. CVP was noted to be quite low (3) and Levophed and more fluid were administered. This fellow was Dx with SIRS. The violent impact had set off a septic-like immune/inflamatory response that caused the low blood pressure. He was weaned of Levophed and was transfer to the ward and was discharge shortly after with a surgical of his fractured arm. It was very wierd to have the patient so profoundly hypotensive without any major injuries.... Cheers

Hello, Like noted above there was talk of transfer the patient to a CVICU/CCU. As luck would have it, he started to come around and was transfer to the ward. Currently, he is doing very well and has return to his normal level of activity. The one new medication that was added was an ACE inhibitor (Ramipril I think). As it turns out he was on an ACE but he stopped taking it because of a dry cough (common side effect). No new treatments. However, improved patient teaching. As the years go on I see this as a critical part of an patient care plan (for EMS and hospital). A part that is often neglected. CHF and DCM was explained to the patient. The importance of daily weights. Simple stuff like that may prevent future episodes of failure. Cheers

Hello, In summary, this fellow was tubed and brought in to the ED ten ICU. He was dx with Cardiogenic Shock. Two theories of the cause were: 1 ---> Off his medications for the scope caused him to go in to VT (according to the pace maker clinic he was defib at total of 5 times for VT). This stunned his heart and resulted in the rapid development of failure (an echo showed an EF of 15%). 2 ---> He was slipping into failure and the stress of the scope caused the VT, the shocks (x5) and the cardiogenic shock. Personally, I think it was a little of option 1 and 2. He was quite sick. He require Doubtamine and Levophed for a couple of days. There was talk of transfer to a large center but he started to come around. He was extubated by day 4 and up to the ward by day 5. Mobey, I agree with your statement about Lasix. Hers is what I should have said: "Or, in some case, after careful assessment in hospital, Lasix to reduce the volume the heart needs to pump." Cheers... Excellent work....