kohlerrf

I am stumped? We all know that we inspire roughly 79% Nitrogen and 21% oxygen at one atmosphere of 760mm/hg. Leaving water vapor out of the mix for now this brakes down to partial pressures of 600.4 mm/hg of Nitrogen and 159.6 mm/hg Oxygen. In a homeostatic body with a proper pH we normally absorb roughly 5% of that oxygen and none of the nitrogen leaving a "partial pressure" void of 5% which is commonly filled by C02 creating the value we know as End Tidal CO2. In addition our O2 sat has risen to 100% because our pH has become more alkolotic causing a left shift in the oxy-hemoglobin curve resulting in greater affinity for hemoglobin to bind with oxygen The numbers may be a little off here but bear with me. If CO2 diffuses to fill the void in the partial pressure, in a state of hyperventilation where our CO2 levels drop what files the void to maintain a partial pressure of 760 mm/hg in our exhaled air? Do we just absorb less Oxygen because the Hemi sites are full and we have saturated the plasma?

I routinely use Midaz for RSI. Usualy I will give 5mg Midaz fast push IV, the pt usualy goes down enough to intuabte with out a problem. If that does not work next I use Etomidate and because I used midaz first I don't have to worry about myoclonus ( an untoward side effect of Etomidate). if that does not work my next step is Sux. Anecdotally I have seen that the rate at which you administer Midazolam the deeper the sedation (all be it short lived) a fast push of 5 or 10 mg is usually enough to knock the pt down you will be able to tell this because when you initially stick the Blade into the mouth pt pulse rate will remain unchanged. If you notice an increase in rate your pt is not sedated enough. Same with the use of Sux if the pt pulse rate rises under Sux it usually means your pt has awoken but remains paralyzed!

I am stumped? We all know that we inspire roughly 79% Nitrogen and 21% oxygen at one atmosphere of 760mm/hg. Leaving water vapor out of the mix for now this brakes down to partial pressures of 600.4 mm/hg of Nitrogen and 159.6 mm/hg Oxygen. In a homeostatic body with a proper pH we normally absorb roughly 5% of that oxygen and none of the nitrogen leaving a "partial pressure" void of 5% which is commonly filled by C02 creating the value we know as End Tidal CO2. In addition our O2 sat has risen to 100% because our pH has become more alkolotic causing a left shift in the oxy-hemoglobin curve resulting in greater affinity for hemoglobin to bind with oxygen The numbers may be a little off here but bear with me. If CO2 diffuses to fill the void in the partial pressure, in a state of hyperventilation where our CO2 levels drop what files the void to maintain a partial pressure of 760 mm/hg in our exhaled air? Do we just absorb less Oxygen because the Hemi sites are full and we have saturated the plasma?

When using a Bag Valve Mask if you are not using ETCO2 you have no Idea if you are ventilating a patient properly. The body and all its organs and systems only operate properly within a very narrow range of pH. We devote a substantial amount of ATP in our efforts to maintain this narrow pH range weather it be through bicarb release kidney excretion or ventilation, second by second the body struggles to maintain the pH so that all systems are "GO"! There is an indirect but very real relationship between End Tidal CO2 and the pH of the blood. The lower the ETCO2 the more alkalies the blood becomes and visa versa. While we do not generally know what the baseline pH of the blood is when we arrive at a patient in the field we do know the body is mapping too and if necessary trying to correct it. If we come along with a BVM, intubate and start to ventilate without End Tidal CO2 we do know you will create and inconsistent minute volume. This inconsistent Minute volume will be reflected in an inconstant End tidal CO2. Because pH moves with CO2 the already sick body will now have to chase and inconstant pH value you create and may in fact never be able to compensate. For every deviation of the pH so goes the efficiency of all the bodily systems. Ventilating with a BVM and no End Tidal CO2? When does the mantra "DO NO HARM" come into play?

EJ's are tough I agree your best bet is trendelenburg. In the old days we use to put a 3 CC syringe on the back of our IV needle and with our pinky pull back on the plunger to create a suction in the needle. Remember the EJ is at a very low pressure and often times you will be in and get no flash! unfortunately you put a syringe on the back of a needle cath today, but the IO work great instead? ;-)

I use Midazolam (versed) almost exclusively. I generally give 5mg fast IV. That is usually enough to put anyone down. My preference it to keep the patient light even breathing if possible and put them is assist mode on the vent in our ambulance. Although, I did have a case last night I had to use SUX. The order went 5 of versed 15 of Etomidate and 50 of Sux. I always use versed prior to Etomidate to prevent myoclonus and although we carry versed ativan and valium my preference in adults is versed, and I only use sux as a last resort when I have trismus.

Not a fan of vasopressors, they have a habit of constricting all the blood vessels in the body including the ones that supply the brain, in addition we all overdose our patients at one time or another because we lose track of time! I have heard, and am very interested, that they are experimenting on swine now using "vasodilators" in cardiac arrest and have had some promising results!

The bougie is the most elegant way to intubate. once you have mastered this brilliantly simple device you will never go back and you can get rid of your secondary airways because you will get the tube every time! Bougie dont leave home without it!

We are a Non-Profit private ambulance service with the contract to provide all the 911 ambulances to our city. we are not funded from the tax base. I would like to speak with any similar organization that currently has in place a "Community Paramedic" or "Advanced Practice Paramedic" program in place. if you could pleas send me a "PM" (Private Message) Ill contact you and we can talk off line. Thanks.

No there is not. But this is off topic although it sounds like the start of a great thread;-) I agree it just seems frustrating when we are the give the task and required to gain the knowledge and held accountable they don't give us the best tool to do the job even though it is readily available and only a stroke of a pen stopping it from happening?#@$$%

My service does not figure in transport time to the ER if the pt needs it you are suppose to do it regardless of where you are. We qualify patients the same way that Croaker260 does My concern is that we use the low dose Albuterol(for bronchial spasm) and subsequently we cant physically get the 10-15 mg into the before and there is resistance of the doctors to giv us the high dose Albuterol for what reason I don't know. In addition being that Calcium is the lynch pin in this protocol we only carry Calcium Chloride on the truck and they wont give us Gluconate either, why again I don't know but the problem here is that the Doc's only rarely give us the order for drip in Calcium because, it is Chloride and not Gluconate. I understand to dnagers of "Rock Heart", although remote, but why not just give us Gluconate which is relatively speaking much safer?

I never palpate the abdomen. no new information will be gained that would ever change your treatment and the possibility (although remote) exists that you may exacerbate what is acutely a minor problem and make it a major problem.

Does anyone else treat for Hyperkalemia in a living breathing patient and not just as one of the 5 H's. We use Albuterol, Bicarb, Calcium and sometimes Lasix.

DigDugDude, Let me speak to you as a "Brother in Arms" and welcome you to the world of critical pre-hospital care. I would submit that your frustration with the current staff you work with is your inability to realize how much you can learn from a medical doctor. Correct this short falling, add a dash of humility and you just might have a future in this business. Every day I go to work I learn how much more I don't know, and I have only been a Medic since 1980. Step back, look listen and feel then slowly move forward. Good Luck Sir!

I agree! You should never palpate the abdomen in spinal trauma or ever for that matter. Information gleaned from abdominal palpation is highly subjective, example; what if the patient is ticklish and tenses up when they have their abdomen prodded? Remember we are not in a warm doctors office with a decades long patient/doctor relationship. More over, there is a possibility (although very remote) that your poking around may exacerbate an existing condition like a fractured L3. Your course of treatment should be based on information that is more objective. I teach my students the technique of abdominal palpation for testing purposes, but I discourage its practical use in the pre-hospital setting.