Mateo_1387

So are they any available 12 leads with inferior ST segment changes that also have ST segment changes in V4?

Great topic. My local guideline directs us to use an 18gauge catheter for pediatric tension pneumothorax. To take a wild stab at Curse's question about infant Tension Penumothorax..... It will probably be associated with trauma, especially to the chest wall, imminent cardiac arrest, and probably diminished breath sounds when listening midaxillary, and shock. Being that we do not have the benefit of assessing the pediatric patient routinely, I guess to come to the conclusion of a Tension Pneumothorax, it will be more associated with clinical suspicion rather than strong evidence. For example, diminished breath sounds, and tracheal deviation may not be easy for us to detect because of limited exposure to pediatric patients. Other signs I figure will be present include respiratory distress, trauma to the chest wall, and shock.

The goal of using diltiazem is to control the ventricular rate, not to convert the rhythm. Normally, electrical cardioversion is used to convert the rhythm. A heart rate of 170 beats per minute or more is dangerous, and will not sustain. At a rate that fast, the subendocardium will be oxygen deprived. Also, at a rapid rate, the oxygen demand of the heart is increased. It will be important for your patient that, say during an hour-long transport, the ventricular rate be controlled. You are also dealing with a patient who has a V/Q mismatch. She has low hemoglobin saturation, which is a late sign of oxygen deprevation. Keep in mind that now your patient's heart is under even more stress to maintain a ventricular rate of 170 and more. Although conversion of atrial fibrillation may occur with rate controlling drugs, it more than likely will not occur. Most conversion is accomplished through electrical cardioversion. Again, in this case, I think it is important to control the ventricular rate, and anticoagulant therapy can be utilized until conversion can be accomplished days later in the hospital. The steroid therapy is for inflammation in the lungs. Since you are hesitant on using albuterol, and rightly so, some form of therapy, if available should be used. Steroid therapy may be an option. Consider again, my scenario that you had an hour + long transport, do you think these treatments would be appropriate?

First off, thanks for giving a fairly complete clinical picture. Question for you, if you were 90 miles from the hospital, and without contact with medical control, how would you have treated this patient? The reason I ask is because a patient who has a heart rate of greater than 170 will become ‘unstable’ if left untreated. I understand that close proximity to the hospital may mean you defer some treatments to them, but for the sake of mental exercise, how would your treatment change with the above scenario? I think the call to withhold the albuterol was wise with the presence of tachycardia. Did you consider the use of steroids? Something else to consider, the Rapid Ventricular Response may be due to her underlying infection, but to treat the underlying infection, therapy will have to be given over several weeks. With a ventricular rate of 170 and greater, the patient will not be able to tolerate being left untreated.

15 L/m is a joke compared to 240 L/m. Exposure to 60 L/m of contaminated gas being expelled is not a joke. Just for the sake of conversation and learning, would 60 L/m still be considered high flow because the flow rate of 60 L/m will be higher than the minute volume of a patient? Also, would 15 L/m be considered high flow for a patient with a minute volume less than 15 L/m, since normal minute volume is approximately 5-8 L/m? At a minute volume greater than 15 L/m, a delivery system that is set at 15 L/m would now be a low flow system, right? Thanks. Matt

WOW. Talk about high flow ! :shock:

And which leads look at the inferior wall? II, III, and aVF. V4 view the anterior heart, and closer to the lateral left ventricular wall more so than the inferior wall. Now, with someone who is Right Coronary Artery Dominant, and having an active Right sided MI could show ST segment elevation in the low lateral leads, V5 and V6, and ST depression in the Septal/Anterior leads.

Using a cheat sheet without understanding the 'why' behind it is no different than using protocols without education. If someone uses a cheat sheet because they have no understanding of the 'why', then they are less of a medic than the ones who know the 'why.' I worked for a service that had cheat sheets, and the only way I would use them is if I went through and did the math to 'double check' the cheat sheet. I found numerous errors. I do not have a problem with using the cheat sheet as an aid, but not to replace understanding drug calculations.

So....using that scenario, let me correct you. I happen to be blowing money elsewhere, and I am unable to save up my money for my twice a year pleasure. We can call that A-fib. The boss then decides to give me a bonus check (for being an excellent employee ) before I normally am able to save up the money. We can call this a PVC. I then use that bonus check to partake in the pleasure an extra time this year. I am premature in partaking in the twice a year pleasure, because eventually I will save up the money for the normal second year pleasure. The only reason I am arguing this point is that Crotch once again tried to shove how he feels down others throats. I simply wanted to show that the definition can change based on the context. There are not very many "set in stone" rules. The only reason the complex is premature is because it occurred before a complex conducted from a random location in the atria. This is a silly argument, I agree. But I was told by a friend that I walk to the beat of a different drum, so I ran with it this time ! :wink:

:cheers:

In that case there would be no such things as premature complexes, as our heart rhythms are never ever truly perfect in timing. The rate is constantly changing ever so slightly. Some folks have it worse than others.

Sure you can. Think about it. ........./............../............/......../........./............../......M..../.......... There is A-fib. The M signifies a premature contracutre of the ventricles. The ventricular complex occurred prematurly because its occurrence in time is before the next ventricular complex conducted through the AV node. Of course, using this logic, it could also be classified as a ventricular escape complex. Ha :twisted:

You are wrong. It all depends on the context.

Great question Doc ! I may have the answer, but if not, sorry for wasting your time. Here goes: While more calcium influx into the myocardial cells causes a stronger contraction, it does not truly explain the length of the plateau phase of cardiac conduction. It may be that the plateau phase is longer so that the action potential can be spread to all ventricular tissue. Skeletal muscle does not all contract at once. Hence we are able to control the amount of skeletal muscle movement. For the heart though, contraction of the cardiac muscle needs to be synchronous. My guess is that the prolonged plateau phase allows time for all ventricular tissue to contract synchronously. Also, since ventricular tissue relies on gap junctions to transmit electric signals, it will need 'extra time' since it lacks specialized conduction tissue. I am not too sure though. Great question to help guide a review of important A&P concepts.

Would putting the mother's hips over the edge of the bed, and the pressing down on one shoulder (supra pubic pressure) be helpful?

I may be a bit off, but this is what I am seeing with the 12 lead. The heart rate is within normal limits, around 64 beats per minute. There looks to be an almost R on T PVC, which is concerning. There is ST segment elevation in the inferior leads, as well as some ST segment change in the anterior leads (V1-V3, as we cannot see V4-V6) This leads me to suspect a right ventricular infarction, involving the right coronary artery. The patient also appears to have P wave and QRS disassociation, which is indicative of a 3rd degree heart block. What makes it interesting, is the QRS is narrow, which would mean the area of infarction would be affecting the AV node, and not the area below the AV node. Injury is below the AV node is usually seen with a wide QRS complex. If the patient develops bradycardia with hypotension, then we can use this information to know that Atropine may be used, instead of Transcutaneous Pacing. Did you happen to do an 18 lead ecg? or a 15 lead?

I do not understand the system either....but Durham does nto fall under that system. The county ambulance provides the medics and the ambulance, the FD is for first response.

Durham County EMS has basics, Durham fire has intermediates and basics

I will see if I can get the protocol for the rest of us folks to see. I know some folks who work for the agency. There is no reason to keep it a secret. :roll:

Happy Birthday Bro ! Glad you were around for another year. Enjoy the goats.

Yea, how will we do all that? :wink: Some things to consider..... Fuel for a six-hour flight. Enough medical supplies and medications for a six-hour flight. Food for a six-hour flight. Where we land to pick up the patient. How to move the patient. Interpreter. Hostilities in the area. Protection. Information for family. Fighter jets to escort

I would probably keep it focused on necessary medical questions. More than likely, the patient will not want to talk to me, but if they do, I will listen. Meh...interesting question. I doubt there will be a need for compassionate statements. The patient will need to know that I am there to care for them in any way possible. The patient guides what any responses to their questions will be. If for some reason there is need for a compassionate statement, it may go something like this... "I realize this is a difficult time for you, there is going to be a team of professionals at your disposal to help you within their capability. Please tell me if there is anything I can do to help you." Telling the patient things such as "Things will be ok," "God loves you," and the like are over the line. If the patient requests you to pray with them, and you are comfortable doing so, then by all means, do so. Keep it general though. Just my thoughts though. I do not have much advice to offer. I will only answer question if I am capable of doing so. Offering advice is not something that most paramedics are qualified to do. The only advice I could see offering is to tell the patient she should be seen at a hospital to receive treatment for any physical and mental harms, as well as to be tested for STD's, pregnancy, and to consider having a rape kit done to catch the rapist. The advice will be more or less things for her to consider, rather than telling her this is what you should do. It is her choice. Other than the previous statements, there is not much more advice I see to give. Physically: Touching a rape patient will be minimal. Before touching her, I will ask. At this time, the patient is going to probably be threatened by my touch. Physical contact should be at a minimum, or so I think. Conversation with the patient needs to be guided by the patient. Let her know that you are willing to talk, if she feels like talking. To make the patient more comfortable, it may be wise for a family member or close friend (the patient's decision) to ride along in the ambulance.

Zero. None that I know of. I have heard people use the 'N' word, but nobody ever makes fun of the Africans. Most of us empathize with the large number of troubles the Africans face on a daily basis. Never thought to look. I would guess people of white skin refuse more. Personally (If you are white, answer these questions): I am I have used the 'N' word. I have told/heard some Obama jokes. I do not recall making fun of Africans though, I have respect for Africans. None. I do not find many Africans in my neck of the woods. I am not married. I would consider marriage with an African though. Zero. Again, in my neck of the woods, I do not know any Africans.

Why the number 25? I am a young paramedic, at 21 years old. I am in charge of an ambulance and patient care. I have a degree in EMS, and am jumping through the ropes. Age should not be so much of a requirement as much as education should be. If the US system were similar to the Aussie system, then the youngest providers would be around 22 years old, and then would have 2 years of intern riding before they are "released", placing them around 24 years old. With that much 'experience' behind them, young people can make great providers. Some of the better paramedics I know are my age. I think a great deal of the older paramedics suck. Seems to me the biggest difference is education though and not so much age. I know a lot of this is anecdotal, but maybe it has some value. I know nurses in our ED who are 20 to 24 years old, and are in essence 'released.' They are great nurses, but they have a team to back them up, and plenty of education to get them where they are. These nurses also have intense programs set forth by the hospital to make the young nurses competent. EMS needs that. First we need the education to set our foundation, and then extensive 'ride along' experience to supplement it. Personally, I think every paramedic could benefit from this program, from the 20 year old all the way up to the 103 year old Spenac :twisted: A blanket age of 25 seems silly. There are young people who are mature, and can handle responsibility. Life experience sure is a great advantage, but it is not everything. To answer your questions Timmy, my scope of practice is the same as the other paramedics. Other young medics I know have the same scope of practice. We all graduated from a college and did not come from an accelerated course. I do not know any paramedics that come from an accelerated course, and are not at least 24 years old. Most 18-19 year olds seem to either go to college, or bum off their parents. One agency close by has about a 5-month ride along program that every employee must complete in order to be released, and afterwards the paramedic is placed with an experienced paramedic. It seems like a good program. The agency also offers an internship. The riding experience is very helpful, especially for younger providers, IMO. Job opportunities are fairly good. Paramedics are in need all over this area, so jobs are easy to come by. Anyone that is young 18, 19, or 20 years old, and is rushed through an accelerated course, and then released as a senior provider, is set up for failure. I firmly believe that with a solid education foundation, and gained experience, even the younger providers can come out strong.