firefighter523

Well i guess a CT is the only thing proving either of us right. I know this, If I can't rule out that his BP is causing his headache, and nosebleed, then I must call and ask the doctor if I can treat for it. If he tells me yes, then I will do such. This pt is NOT presenting with a SAH, he is infact presenting with a HTN crisis. Go back a reread the hx. I find it highly coincidental that he got a headache at the same time his nose started to bleed. The fact that his headache went away when his nose started to bleed says it all, - CONTENT REMOVED - I have treated many pts with command ordered nitrates, and many have resolved at least some of there symtoms. -CONTENT REMOVED- ADMIN

Doc, With all due respect, your rx for any pt is subject to scrutiny, from other physicians. Just like our rx for our pt are by other paramedics. I do not have the education that you have, and do not claim to know it all. We have protocols, and for a good reason, and they are made up by people like yourself, doctors. We do not have beta blockers in our region, (yet). We only have loop diuretics, opiates, and nitrates for HTN. And we are at the mercy of the doctor on the other end of the line, as it should be. Dont think for one second because you are only 1 of 2 doctors on this forum, that your word is gold. We use nitrates or diuretics for what might be a HTN crisis.

JPIN, I am sorry you have waisted your time typing all of that "stuff". Wait until you are atleast a medic to argue with the big boys! I am a college student also, do I seem better now??

JPIN You must have missed my reply when I said that beta blockers would be a better rx modality for this gentleman. Calm down your eagerness to argue and read the full text of the replys.

JPINFV, Your statments are irrelevant to this case. Nitrates lower BP, and that is what he needs.

AZCEP, This is not a bleed, you are analyzing this too much, and the treatment for this gentleman is to lower his BP. 160mmHg (diastolic) is TOO high! NO EXCEPTIONS!!! Go back and brush up on you hx taking skills, or education, one of the two!!! You ask me why I would do something that would cause a problem? The problem happened already, I want to fix it. If his Bp is that high, I DOUBT THAT HE WILL BECOME HYPOTENSIVE. The fluid bolus wouldn't be needed. I was just schooling you on what to do if it does drop, in any case because of too many nitrates. You wouldn't wait 5 minutes till it wore off. Is that clear now "instructor"??

PS AZCEP, If the pt goes hypotensive, you lay them supine and give them a fluid bolus! You DONT wait 3 to 5 minutes for the nitrates to wear off!!! Don't get stupid because I piss you off, use your head!!

AZCEP, the guy was standing, cooking, got a headache, and his nose started to bleed, he also has a hx of HTN. Apparently his gcs is 15. SAH does NOT present like this. If anything does, it would be an epidural bleed, usually from the middle meningeal artery, usually with associated trauma. Subdurals are SLOW to present. You DONT usually get nose bleeds with them, and they DONT just disappear (headaches). You need to correct the insulting problem, pt's like this USUALLY have hx of HTN, and are not compliant with there meds. 160mmHg is too high to let be. I can understand if this was a hem, BUT IT'S NOT!!! This pt needs his BP lowered, hence that is PROBABLY why his is on BB's!!! If you don't have BB's in the MICU, you need to use what you have in your box!!! I resort to the name calling because there are people on this site that think that you should NEVER lower BP in the field. Yes , they truely are IDIOTS, and I really don't have a problem with telling them that! If I had a beta blocker, I would ask to give it. That would be the best thing to do.

Scratrat, ???????????????The BP thing.............. Start over with the whole paramedic thing, infact go get a job more suitable for yourself, like in a barber shop or something!!!

JPINFV, Yes, you would lower the heart rate. Do you know how you would do that?? VASODILITATION. The heart beats faster because it has to pump against an increased vascular resistance, you take that away, the heart says thanks. :?

AZCEP, Since when do you have a lack of control giving nitrates???? You give them every 3 to 5 minutes for a reason, because they wear off that fast. :roll: That is why they are the cat's a## in CHF. If there BP crashed, you lay them down, and give them a fluid bolus!! Amazing, isn't it??? All of the time you have to read those books, I am suprised you didn't come across that :shock:

What? Hah?..... I guess you could talk to the command doc that gave me orders just the other day to give a pt with the almost exact same complaints, NITRATES. If you would READ , and maybe REREAD the Hx, you could clearly rule out a SAH. The pts head ache went away, how the heck you you expect someone with a very bad head ache associated with a SAB to just all of a sudden go away, her nose started bleeding, and she went complaint free. For the people who believe that you shouldn't lower a pts BP in the field with any complaint associated with a diastolic pressure that high, and you can rule out SAH, ie... no hx of trauma, no more headache after her nose started bleeding (big one folks) and good equal and reactive pupils, and the fact that she has a gcs of 15, you should not be practicing. Correct me if I am wrong, but if a pt's BP is above 180 systolic, you cant give TPA anyway. You all are making a mountain out of a mole hill. That is just ludacrist, not lowering a BP in the field that is that high!!!

I had to go and reread the hx. I would transport this pt as a moderate priority. No light and sirens, but a full als work up. It doesn't sound as if she has a SAH going on. Her headache is no longer, she is not nauseated, she is concious, with no blurry vision, and from what I can see she isn't even on coumadin. Diastolic of 160 is very high, I would definately try to lower the BP. Sounds like she popped her top!

Any pt who has any complaints wether, it is dizziness, photophobia, headache, diplopia ect.. with a corolation of a diastolic above 110mmHg would get a full als work up as well as nitrates enroute.

So, you are banking on being right on with the amount it will take him to maintain 10 breaths per minute. It is much easier to restrain someone who is unconcious then someone who might be fighting you, because you misjudged your titration. Believe me, it works well, especially if you have a ton of other things to worry about, ie... extracation. If he is secured to the reeves, ticked off, but breathing (high flow 02) then thats ok, at least he is secured and breathing. Wether he is mad, is not our problem. Also you have no idea of the pharmacokinetics with each pt, ie... how much of any opiate they might have taken, you have no idea how narcan is going to work for this pt, or any. It is better to get him the full dose, in the controlled environment that you have created, then to wait around to see if .4 actually worked for him, don't you think.

A good practice to get into, is if you suspect a narcotic OD, to take the short amount of time (after you place the pt on high flow 02), to place the pt in a reeves stretcher, and cravat his two hands to the handles on the side of the reeves. That way, when you awaken him, he is on the 02, and secured into the reeves. He can't spit, or throw punches, you are in total control of them in most cases.

You all are quite right, It is actually getting very boring now to see all of you get your panties in a bunch. It's not as fun as it used to be What's wrong with tattoos????

No, yes, no is not bi-polar Ruff. That is indecisiveness, being mad and irrate one minute, and all lovy dovy another minute, (giving group hugs) is bi-polar.

It was a joke, here is another tissue, for crying out loud!!!

Ruff, are you Bi-Polar??????

Ruff, do you need a tissue?

And Flight-Ip, Get off your high horse, the only thing different between you and I, is speed and paralytics!! You are just another number!!!

chbare, I called Ruff out, because he pulls stories out of his single branched family tree back in Kentucky!! The point I am trying to make, and this goes out to all on this forum..... If you are transporting ANYONE on ANY KIND of device that you are not familiar with, you should NOT elect to take that transport!!! Ruff's post indicated to everyone on this forum that by the Grace of God his pt survived that transport. If that IABP failed in any sort of way, you NEED to know how to trouble shoot it. I personally will not take a transport with an IABP or VAD or any device for that matter if I haven't been trained on it!!! That is why they educate people in critical care. That is why they came out with courses like CEN, CCRN, CFRN, FP-C, ect.... What might have been done in the past is just that. However, that prior statement about the past will NOT save anyone in court when a person dies on them because of machine failure and they didn't know what to do other then ACLS!!! PHWWWW........ and people call me the renegade paramedic... Shame on you Ruff, for putting that pt at risk, and putting the family at risk for losing their family member because you didn't know how to render care!!! I could care-a-less if you have 15 years of exp, you act like an EMT fresh out of class!!!