FireEMT2009

Yea if im setting up a med drip i use the Dosage needed to be given, times, drop set, divided by concentration like you stated earlier. I use my calculator usually so my drops are correct because I have alot of trouble working with big numbers in my head, and usually if I'm doing a drip like dopamine I don't have time to get a piece of paper and pencil to write it out.

You are dispatched to a patient with abdominal pain, with bleeding. You arrive to find a one story house with one car in the yard. You knock on the door announcing that you are EMS and here to help. She hollars that the door is open and to come on in. You arrive at the patient, a 37 year old caucasian female, in the foyer of the house sitting down in a chair. Go from here...

After talking to a very respected medic in the company, they taught me an easy way to calculate a dopamine drip for a patient as long as you are using the standard 1600mcg/ml bag (double the drips for a 800mcg/ml bag). For every 5kg you add 1 drop. so a patient weighing 100kg would get 20gtt/min at 5mcg/kg/min. (I worked the math out myself and it works perfectly). Just thought someone might appreciate that sometime or another, I know I did.

I agree with everyone else, relax. And always remember use common sense on ever answer.

Well lets start from the beginning, Airway- Open patient? Audible sounds (stridor, gurlging, wheezing)? Breathing- Respiraton rate? Breath Sounds? capnography? Circulation- Pulse quality (strong, weak, irregular, thready, regular?) Labs showing any imbalances of electrolytes anything? Any other history of heart problems except for CHF? If they did an echo did they find anything? Has he been this cyanotic the whole time? Is this mental status normal for him? Has it deteriorated since his arrival? Any trauma or other medical history? Any food or drug allergies? Is he on oxygen now? if so how much and by which device? What is his blood sugar (strange yes, but I like to cover all bases especially with a severly cyanotic patient) Is the amount of cyanosis normal for him? Congrats on the 1800th post!

We did the tilt the patient but it did not improve anything but I will look more into the 30 degree thing through. Thanks! Its easier to show you a picture so here is the Nexiva closed system I was talking about: The needles the other hospital must not be a jelco but it is the one that the needle retracts into the barrell like this: For the EJ I used the first picture one, except in a 20 gauge not a 22.

Hello all, As many of you know I have had many concerns and questions about EJs. Well in my last clinical rotation of my paramedic program I was given the chance to do an EJ in front of my OMD. The hospital I was at uses the Nexiva closed system IV catheters if you are familiar with it. The other hospital in the area uses the protectacath (Jelco) needles. The hosptial I was in that uses the nexiva keeps a couple of the Jelcos around just in case and for large bore IVs due to not having the nexivas in 14s or 16s but I digress. We had a patient that had been stuck numerous times and could not gain peripheral IV access. So I asked my OMD if he would allow me to do an EJ (It is a doc only skill in that hosptial). The doctor came and attended my EJ. During the proccess we could not "see" the EJ but it could be palpated and a slight buldge appeared (dehydration/hypovolemic). I stuck at the site with the nexiva and never got flash, after about a minute of searching the needle was withdrawn and peripheral access was finally obtained elsewhere. I have heard that the nexiva needles are not the best for doing EJs, has anyone ever heard of that before and if so do you know why they aren't the best IVs for it? And can anyone give me any EJ IV cannulation tips as well. I occluded the base of the vein so that it would stick up more during the procedure. Any advice is welcomed with a clear and open mind. Thanks! FireEMT2009

Mike, I apologize that came out completely different than what I meant. I treat kids as just that, kids. I completely understand that pedi assessments are different than adult assessments and have learned that with scenarios in our lab setting. I meant as in ABCs are always first just like adults, except that kids are alot harder to manage compared to adults. I apoligize for my mistyping. I am working on learning the dosages, memorizing i have come to realization, that it only stays long enough for the next test or the next couple weeks but not the next couple of month or years depending on when I need them. I work hard to memorize, understand, and fliter out the drugs of which I am administering, whether adults or pediatrics. Thank ya'll for the advice. I will continue to keep ya'll updated on my progress and continue working hard throughout the rest of my time in medic school. Its better to learn your mistakes in the lab setting than the real deal. Thanks for the great advice so far, FireEMT2009

Hello everyone, I made a topic about this a couple of months ago and just thought I would give you an update and have some questions that I would like some insight on that I can get nowhere but here. First off, Peds seems alot like an adult assessments, ABCs come first (DUH) and that the browslow tape is your BEST friend on peds patients. I would also say that it seems to be clicking with me very easily and am truly enjoying my class before PALS. I test out in April and will be taking the NREMT-P and I know there is no browslow tape allowed on the wiritten. The questions I have are: When you are dealing with drugs that aren't on the browslow tape (i.e. albuterol, diphenhydramine, phenergan, odansetron, etc.) how do you remember all the drug dosages? I understand that 99% of all the drugs that are used on peds in a critical situation are on the browslow tape. I am just looking for some great insight that I know this site can offer me. I also have found that the "generic" (i use this term loosely in this situation) is 0.1mg/kg. Thanks for all the answers that I hope to come. And in case I haven't said this before, thanks for all the help and advice ya'll have given me so far in my education. FireEMT2009

Ventilation is the act of moving air in and out of the lungs from the outside in or vice versa. Respiration is the act of the transferring of oxygen molecules to carbon dioxide molecules which is what happens at the aveoli-capillary level. I need to fix my signature cause I can not truly cause respiration due to having no control over a person's respirations. I can cause them to ventilate. I will correct it ASAP. Thanks Mike! FireEMT2009

Yea, I have realized in my time here precepting for school that using other medics advice is helpful but at the same time might steer me down the wrong path, especially when they try to pick my brain and I end up getting in my own way too much.... Had that happen a bunch of times but thats an obstacle im working to overcome and a thread for a different day. I try and get a ED doc or whatever specialty doc I can talk to's advice so that I can better think and rationale things. My OMD for my school comes in every month and challenges us on drugs making us give him rationale why things work the way they do and why they don't work on some things. I really learn alot from that and him overall., I appreciate the constructive criticism. I am trying to improve my forum rapport through breaking up my posts and communicating more fluidly. The contractures through me due to the fact that I have started IVs in the ACs of patients and as soon as they bend their arm, BAM its occluded and It no longer runs fluid. I was confused because I figured no matter where on the hand or AC I can start the IV it would be occluded by the contractures. I have not had much luck with forearm veins but did get a nice stick today on the back side of one. I would start an EJ on a patient needing IV access. The patient in this scenario was not extremely hypovolemic, but could have definately used some fluids to help replenish some of the fluids he had lost over the time frame of his sickness. I have been told EJs are always for last resorts by every medic I have worked with in the field that is why I am hesitant. Also I have never started one bbefore so it is alien to me right now. I would perfer to use the response I gave to Dwayne about listening to other people as the response to your question instead of retyping it all over again. About my status, It is meant to be seen as I can make someone breath, whether by face mask, ET tube, LMA, combi-tube, king airway, etc. I have always had the motto that is set as my signature and that is why I placed it there. I should update the wording of it cause apparently I did not proof-read that very well either. ABCs always come first and you can't have one without hte one prior and all three has to be present to have life. Hopefully that clears it up. If not please tell me how to better correct it. Thanks Dwayne and Mike. FireEMT2009

normally I would have started an IV in this patient but the contractures had me confused about where to start said IV. I have no actual status saying that the EJs are only used for Codes and Traumas, it is jjust hearsay but i am relatively nnew and am taking it from the medics i precept through.

And Defib, Epi could possibly cause the baby to go into cardiac arrest. You are trying to increase the contractility, rate, and oxygen deficit of an already overworked, overstressed, and under oxygen fed heart. Epi is the exact opposite, and epi will cause vasoconstriction instead of vasodilation. Epi is definately not the drug of choice of this little guy. I would stay away from those type of drugs especially since epi has a high oxygen demand.

With this child you will more than likely never acheive near 100% O2 because the heart isn't pumping blood adequately so no matter how much oxygen you push into this baby it will only raise it someone what. Romney, What is the normal O2 sat for this baby?

EJs are allowed for traumas and codes, IOs are only for the most critical patients. That is our setups here in my area. I was thinking that the back of the arms would be a good place. I am a paramedic student in a place where we are only 5-10 minutes from a hospital so we have very short transport times. edited to make an addition to of my sentences to make it understandable.

I truly have no idea how I would treat this child prehosptially. I would have to treat the symptoms as they appear. I am completely lost. I would definately want to call the child's cardiologist and get him to tell me what I need to do. Med control on this one. Is my treatment plan missing something or am I just way off into left field? Had the parents been giving their child their meds religiously like they are suppose to? What made them call 911? this is extremely strange to me since the parents couldn't handle the situation on their own so they called us for a reason. What's the CC via parent's report?

After googling it and reading it on pubmed health it is where the left side of the heart is not matured enought ot support the demands of daily life. The cyanosis you are seeing is normal for a child with this condition because the left side cannot produce the pressure needed to deliver oxygenated blood to the body. Therefore the right side has to do it all, which will cause failure overtime. The Noorwood surgery that you posted originally is where the surgeons form a new "aorta" by fusing togeter the pulmonary veins with the coronary veins and attaching them to the old hypoplastic aorta. Since the patient can only stay alive by keeping the ductus arteriousum open so that oxygenated blood can pass through the heart. has the parent given the patient their medication today or the last couple of days? If not then you need to get them to the children's hospital ASAP. The child needs the children's hospital because they are specially trained for this and more than likely will have the pediatric cardiologist that is the doctor for this patient. I would go with a sense of urgency to the pediatric hosptial. I would keep constant checks on their vitals and ekg. The ekg will probably be pretty funky due to the changes the heart has had to go through to continue to supply the body with oxygen. The low O2 saturation we are noticing is not going to be uncommon due to the lack of the left side to properly send oxygenated blod throughout the body. Therefore the pulse ox monitoring would be near useless. I would place the patient on blow by oxygen right now and transport urgently while monitoring their vitals and continue getting the history from mom on the way to the peds hosptial.

99% of the time I will feel for veins more than relying on sight. Wouldn't the contractures inhibit the ability of the IV to flow due to compressing the veins?

I checked the foot and did not see any suitable places for venous access. I was looking at the forearm because the contractures would not occulde the IV sites.

You are treating a patient with constant contractures bilaterally at the elbow and wrist levels. Both of which would occuld IV sites. You need to start a line and give some fluid due to hypovolemia. I was thinking of the forearm are the upper arm/ shoulder area. Where would ya'll stick? I had a patient like this and was just getting an opinion from more experienced medics. Thanks FireEMT2009

For all the times: Attempt to sedate the patient with versed, ativan, whatever sedative you have available and with an OPA and BVM with nebulizer. If the sedatives work as I would hope them to then I would attempt to reintubate and continue my neb treatments. As long as you have an OPA and BVM you have an airway of some sort. RSI needs sedative/anesthetics and paralytics. I would use it as a sedative assisted intubation to help the gag reflex and to ease the patient's suffering on the tube. I would use the versed or whatever sedative you have available at your disposal to help facilitate better airway management for my patients.

SW Virginia for college. Southern VA on the border of NC originally. Why?

Yea i test for my paramedic in April so I am working on my last clinical rotations this semester and will finish up my field run time next semester. The sooner you give the corticosteroid the sooner it will work so it can only help your patient in the long run. And yea not having a "living breathing patient" in front of you makes our field decision alot harder than it already is.

We just got Versed here where I am in college for my rotations and our new protocols should be out in the next couple months. Luckly you can hook up a neb to a bvm without much problems as long as you have the T connector and the neb tube and connect it from the BVM to the mask. We do not have decadron here but we do have solumedrol. I am hoping to see that when the new standards for the scope of practice take full effect that it will open up new horizons for our protocols especially for these types of patients so our hands aren't tied up with this situation.