srs911

"Albuterol can affect K levels, driving K+ into the cell (the exact physiology I can't quote of the top of my head)" Neither can I, but the question came up in another forum last month and I had nothing to do so I cracked a book and put this together and posted it, so will throw it out here also: Quick answer: Albuterol causes an decrease in serum potassium levels because of its effects on the Na+/K+-ATPase pump (increases activity, more K+ into cell) and it's promotion of insulin release (increase insulin, more K+ into cells). Detailed answer: First, albuterol shifts K+ from the extracellular space to the intracellular space by increasing Na+/K+ ATPase pump activity. Specifically, I believe that albuterol upregulates cAMP, resulting in increased pump activity. Recall from cardiology that the pump moves K+ into the cell in exchange for Na+ out of the cell; increase activity, put more K+ into the cell form the extracellular environment, serum K+ falls. Second, albuterol increases the secretion of insulin from pancreatic islet beta cells. Insulin promotes the shift of K+ into cells via activation of the normally inactive Na+/H+ exchanger (NHE) located on cell membranes. Activation of the NHE results in a K+ shift into the cell and out of the extracellular environment, serum K+ falls. That is kinda neat in that it makes intuitive sense. Think about it, you eat a banana, take in lots of K+ that would kill you if you could not redistribute and secrete it, insulin is released as a result of eating and in addition to shifting glucose into the cell it happens to also activate these two mechanisms that regulate serum K+ levels. Neat. Hope that helps explain it.

Yes to both. My rules o' thumb: 1. BLS patient but not sure what's up? Get a BG 2. ALS patient/Start an IV = get a BG 3. BLS patient with a diabetic history? Ask myself "why shouldn't I get a BG?". If I have a good answer (like, they called for a hangnail), fine. I am of the opinion that there is not much room for question here. It's another tool to be used, like a stethoscope; why do we listen to and document lung sounds on a patient with a twisted ankle? Because we recognize that missing a respiratory insult can be detrimental to the patient, as well as our freedom to practice paramedicine! It's automatic. Try to think of obtaining a BG in the same light... sure it's not likely that the guy who presents with a broken leg after dumping his motorcycle has a decreased BG, but it could be the case (maybe that's what caused him to dump his bike?). And with that MOI he's probably a precautionary ALS anyway, you're starting a line, take the BG. As far as cost, all the services I have worked for (6 total) have never charged extra for BG determination, so considering cost to the patient was never a factor and has certainly contributed to my views on this matter. I guess my feeling is just check it unless it is so freaking clear that BG is not an issue you would bet your dog's life on it. Let me make myself clear, I'm not saying that every patient should get a BGL. Plenty don't need one. However, plenty others require one. Takes a few seconds, is a useful piece of data, and i guarantee you that if you do this job long enough there will come a patient where you never though that BG was a factor, you catch it, and you management decisions will change based on it. I error on the side of caution, and never presume that I know all of what is going on unless I check it. Here's another thing to consider, especially you guys/gals with considerable experience.... a lot of paramedic students and new paramedics come to forums such as this to get info, which is often provided by peeps with some experience. Addressing this specific thread, should a new paramedic error on the side of taking too many BGLs, and develop through experience (albeit anecdotal) a sense of who "needs" BGL determination or should she error on the side of taking too few?

I don't think that the issue is will there be tracheal deviation in a tension pneumothorax... there will be. I think the more important question is "Is the tracheal deviation that accompanies a tension pneumothorax easy to identify on physical exam?" The answer to that, in my opinion, is no, and the pic of the very impressive tension pneumo that is accompanying this thread shows why. Take a look, no doubt there is tracheal deviation. But look above, say, the sternum, and the trachea isn't all that deviated from center. It is, a little, but not all that much, and we're looking an x-ray. Throw a bunch of adipose tissue over that neck and you might agree that it would be difficult to identify... not impossible, just not very obvious as many people think. I know some will say that you can palpate the trachea to see if it's midline, but agian, if it's not all that far off I don't know how easy it will be. And don't forget that this is about as bad as it gets (though you wouldn’t believe it by the description of the patient... unreal!), do you think that it will be easy to identify tracheal deviation on an emerging tension pneumo? Again, my opinion is no. So, while tracheal deviation certainly looks impressive on x-ray, CT, whatever, I think that we should concentrate on other clinical signs and symptoms to aid in our identification of the problem: MOI (trauma), history (bronchorestrictive disease), or body type (tall thin male with pack o' Camels). Worsening tachypnea, tachycardia, and hypotension leading to respiratory and cardiac arrest. Decreasing SpO2. Diminishing then absent lungs sounds on the effected side, maybe diminished on the opposite as well. Tympany to percussion on the effected side. JVD, if the patient isn't hypovolemic. If you see tracheal deviation, great! Did I miss anything? Again, I'm not saying that tracheal deviation doesn't occur, my argument is that we, as EMTs, medics, and especially educators, should place more emphasis on all the other indications and not get hung up on tracheal deviation. Anyway, that's my 0.02, based on my anecdotal experience, nothing based on science. Take it for what it's worth.