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GENTS: The 5 to 7 ml/kg. based on ideal body weight is now the accepted NORM, a very large study worldwide found (NEJM Sept. 14, 2000 Vol. 343, No, 11) That "VOLUTRAUMA" was indeed a large factor contributing to ARDs, in fact prior to end of the study (approximately 75% of results in) was so conclusive that the study was concluded....oh.... I "MUST" add that the baseline PEEP level of + 5 cmh20 was used in this study as it it is a protective mechanism to prevent (micro) atelectasis.....EVEN in those in the "head injury" category. OMG, totally radical eh what? this does not inadvertently affect ICP which was a thoroughly evaluated in an other study (can't find that one, oops) As a rule of thumb, the concept is: Keep plateau pressures (static compliance) less than 32 cmh20, this can be difficult to calculate on most transport ventilators. This based on the assumption that (on average) 8 cmh2o pressures is the result of (dynamic compliance) on a clean # 8 mm ETT with flows in average 40 t0 60 lpm. hope you are following so far. Soooo in the back of the truck/bird....if one eyeball's the PIP (Peak Inspiratory Pressures) try to keep PIP less than 40 cmH2o then this can be accomplished without too much difficulty. If one encounters ETCO2 levels rising then pick up the rates not the Vt's. Targets shoud be ETCO2 of around 35 to 38....this accounts for "Norms" granted the pathophyiology of the acute lung injury can be affect these reading but lets keep it as simple as possible. The concept of ventilation is that CO2 is dependant on Minute Volumes Rate x Vts....lets stay away from VD/VT for now...k? It is also mentioned that in the asthmatic patient or the very difficult to ventilate crowd that 3 to 5 mls per kg is acceptable, note these values and suggested guidelines are buried somewhere in the guidelines of the "OLD" 2000 American Heart Foundation International Consensus on Science #239 Part 8 Advanced Challenges in Resus: page #239 as is permissive hypocapnic ventilation... in fact if PH of less than 7.25 then bicarb can be added, numerous on going studies are pointing towards acidosis at the cellular level 'could be" protective homeostatic mechanism yet to be determined. While your at it a great brief on Auto PEEP as well, not really indepth but and just my 2 cents would be that this unrecognized condition if far more prevalent than first believed in EMS.... a relative mechanical hypovolemia...leading to PEA. A very common point observed when a rookie is told to squeese the BVM.....slow down dude, its not a ballon! I digress...sorry got on a roll there, look back in the SOB OBS thread (or something like) a GUEST? made a post there that was quite interesting a "medics" explanation of Auto PEEP. General rule is that Hypoxia kills yah way quicker than Acid base imbalances. Oxygenation as stated by "ERDOC" when a patient is this acute ABGs should be used as the "Golden Standard" as the evaluation tool. Oh Dust...if my SATS were less than 85% I would call it "STATS" too.....LMFAO. Do I get points deducted for rambling? cheers oxygen boy...... aka squint.

Resqdivemedic: Thank you eh, I was hoping that someone had seen these device besides myself, was beginning to think I saw them in a Hollywood movie or something..... Were you in involved in the studies in New York or the Windy City or did you use them in the military? Thanks for the heads up, the link is http://www.morningpride.com/products/default.asp?p=5 if anyone wishes to check it out appears that one could improvise with a plastic bag or 2 if one had a boy scout knot "how to tie knots badge" cheers

Question would be the time frame from ingestion, to nausea....good old natures way. Tylenol has a nasty habit of prolonging peak onset for up to 24 hours, somethimes longer. Really rough on the liver and kidneys as well. I suspect that the hospital initiated N-acetylcysteine (Mucomist)? cheers

Just a question here (at this part of movie I usually eat popcorn) If one is hypotensive, even from hypovolemia and not trying to put words in ones mouth here.... BUT would it not be logical that they are already hypotensive (not producing pee pee) therefore the kidneys are already hypo-perfused? I was always under the impression that Dopamine (#1 trope on the hit parade) improves renal and mesentaric artery dilation? Dopamine can (defendant on dose delivery) affect the drain size as well, (in reference to your analogy). So just for argument sake, why not start with Dopamine?..... after the Dr. Placebo and Oxygenation concerns are resolved, whatever way one wishes to deal in that regard. Fact of the matter may be that a trope may be more beneficial in the decompensated (circling the drain crowd) whether it be from septic shock OR cardiogenic....just thought I would throw that out there. Perhaps a study even, could put a mark on the wall for EMS practitioners? :wink: As for the reference to percentile in correct Dx of experienced, well trained Medics out there, by your own admission as well 90% is pretty good odds I'd say? First off no point in even trying to answer this Asysin2leads.....you are playing the village idiots helper their and I won't bite at that hook...I do read YOUR posts....lol. The confusion some time exists as "rales"......Rales are wet, crackly lung noises heard on inspiration which indicate fluid in the air sacs of the lungs. Rales are often indicative of pneumonia. See also rhonchi, wheezing. rales is a 'very old term' and sounds are more indicative of course secretions ......if the rattle improves with cough and have the patient "hork"(an approved medical term :twisted: ) in a K basin the picture this can become quite a bit more clear. "Creps" are far more indicative of pulmonary oedema, (sometimes the give away is pink frothy sputum!) bit of an D.G.A. (dead give away) cheers note: edited due to sub therapeutic caffeine level on initial posting.

[ asy gee I am blushing! Odd you refer to the Inuit, as I too "personally" have more than one word for Snow. @#$$!^@ !!!! #@$% ^"@#$ it is cold. and last but not least $#@&%%@@$&**( in my boot) I seriously doubt there is a Translation in Hebrew. #$@% is falling in the mountains as we talk....it is 7 degrees Celsius outside today. Time to find something warm for my sleeping bag...te he. cheers

Just a curious here: What setting (s) do you initially start the with on your patients with CPAP or BIPAP? And (in your respective areas) do you have criteria established that excludes the use of CPAP or BIPAP, especially in Hypotensive states. Just a personal comment here: I have found that most ventilators can be used for NON Invasive Positive Pressure Ventilation usually those that are more expensive, the criteria being those that have adjustable PEEP settings, and Pressure Support Mode, and Peak Inspiratory Flow rates exceed 50 lpm. Adjustable "slope" or "% rise time" are superior in regards to "titration" to patient comfort levels and tolerance in my experience. NEJM Jan. 14, 1999-- Vol. 340, No 2. Question posed would be what types of Machines are being implemented in the Pre-Hospital Care World? EDIT Rereading the prior discuss: . There is some evidence that early administration may be beneficial in the asthmatic patient and on spec. it has been used here, the actions of steroids an not fully understood as of yet, but does stabilize cell membranes. Granted Asthma is not the topic here (although stimulation of key receptors in the airways may be triggered with a flash PE) Beta 2 adrenergics as well are used to improve oxygenation, but caution should be excersised in regards to the degee of distress (heart rate commonly can be a used as a guideline) although in passing: MOST of these patients are on Beta Blockers these days further complicating this pathphysiology. Evidence does exist to support this theorem in a similar related topic NEJ MED 1994:331:286-9 cheers

These comments forward from another listserver from another experianced desert "Hiker" Hey squint, as she probably knows she in a bad spot without much help. We found here in the Iraq desert that prevention is key. So we hammer it in at every morning meeting and pay attention to the weather. For us we usually have problems early in the summer and when it grows hotter then 110 F. We were able to obtain a small freezer which is loaded only with water bottles which of course freeze over night. We then load the portable ice chest with these bottles and on most days we maintain a decent supply all day even when we hit 130F. If we need the ice the we either use them as is or crush them and put the remains in plastic bags. You can also wrap the IV line around the bottle and it will cool the fluids as they flow from the bag. But prevention is key Patrick C.

These comments forward from another listserver from another experianced desert "Hiker" squint dude.... Having spent time in hot places, our doctrine at the time was very specific in terms of rigid acclimatization schedules and hydration. The key being prevention. Now if it still happens the best way of cooling down without the benefit of immersion /conduction is by convection saturate body with water and fan, cool packs to neck, groin, pits, paying particular attention to keeping the noggin cooled down, IV's & benzodiazapines also help with prevention of seizures and internal cooling. As I stated the key is prevention and timely acclimatization over time, color of clothes and type is also critical. I have attached a link to the guide we used, if it doesn't work contact me directly and I'll send you the PDF. http://www.usariem.army.mil/download/heata...%20schedules%22 Also see this link for more info on heat treatment and prevention http://www.usariem.army.mil/somalia/heat.htm

These comments forward from another listserver from Aussie friend on an offshore Platform. Hey asy: This may sound uber basic but how about some of those 'instant ice packs'. The ones that you punch to activate. Fairly light and very economical. About six of these in a small first aid pack. One under each armpit and one on the back of the neck (wrapped in a wet cloth as per normal). Always worked for me trying to get core temps down from 40-41 etc. Couple this with initial cool water intake and IVT and you may have a win there. The 3 spares are for evacs over 20 mins as they will heat up in about this time. Patients with temps hate these so it gives you some revenge on them for being such a twit in the first place. Very basic but also very economical. Also, get the 'rescuers' to carry a 'Camel Back' type device that you hold at the first aid station next to the ice machine. Slap some ice in it on the way out and this gives you a good lightwieght source of cold water for the casualty to inbibe as they see fit. And the usual rehydration salts at the first aid station for arrival. Let me know if it works mate. Cheers, Mick PS: Are these people inducted and if so, the safety officer should be getting into them in the induction about monitoring urine output and adequate fluid intake.

For the statement above...ANSWER: TRUE

asy: Firstly GREAT to see a post from you. Wow that's quite the scenario you have there, perhaps convince those tourist to GO HOME or perhaps visit Hell instead. Being from a country notorious for the opposite environmental challenges I am no expert but I will look for you, would really like share some of my conditions ie "snow" with treats of it soon, I doubt that Fed EX delivers in refrigerated units where you are, this is intended make you smile. I have heard that an improvised Camping Chair is being used in warmer climes for firefighters, (in bunker gear that is difficult to remove similar to conditions you may be seeing) the ARM REST portion has sewn-in, and lined plastic bags filled with water and ice in which to place their forearms but if the ambient temperature of available water is higher than body core temperature this may be problematic. I have heard that this was trialed in Chicago ? and New York ? I sure hope there is more input here from those others that support you when they see your post. There are a few really expensive high teck. very expensive body suits but I promise I will keep looking for you and ask some experts. cheers.

Respected Sir: I find your post most interesting, although I do not practice routinely in the US of A it was noted by myself that while on a visit to Baton Rouge and through discussions with Acadian Ambulance training staff under the direction of DR. R. Judice. He has implmented, a "patch before admin" Lasix standing order as well, I was uncertain as to rational of this but with your post I am more enlightened. In Canada we have a touch more latitude in practice most possible due to geography moreover, frankly I have not personally observed the inappropriate use of Lasix in a mis dx pnemonia, granted not to say that it does not occur. If you be so kind could you please provide a link to the study Hoffman et al many providers here could benefit I am certain as previous posts are making me a bit dizzy, you demonstrate clarity. A further point may be was that this study was available to ILCOR when reviewing literature and while in preparation of NEW CPR and ACLS guidelines... still waiting for the printers to get that out in Canada...sheesh. Has the AHA modified its views in guidelines as of this time with the suggested use of lasix? With some experience in the Critical Care setting quite frequently (in decompensated CFH patients) the use of Inotropes has been advocated by Cardiologists, granted this does present some difficulties in posing a study to be certain but is does make some sense to raise MAP resulting in increase renal perfusion, therefore improving the efficacy of some diuretics. Comments on the use of BIPAP: as CPAP stand alone I must totally agree will increase WOB! This is why in some ER's the pressure supported levels are implemented, unfortunately initial application of base (PEEP levels more correctly) and PIP have never really been studied to the best of my knowledgde. Anecdotal success in application can be the dependent on the experience of the clinician, granted not every REMT-P out there has expertise of an RRT nor should that be an expectation. And additional request would be for the less knowledgeable to please explain BNP in a bit more detail thanks. I am forget my manners, greetings and a big WELCOME to EMT city! cheers

Just a little story to make you chuckle. Was southbound out of Edmonton headed lights, no sirens it was low traffic @ 04:00 hrs. to pick up a sick kid in Red Deer, about 60 miles away and NOT sparing the horses I may add. Got pulled over my the RCMP my partner said $#@^ HIM, but I stopped, the officer then opened up the back door of the Neonatal "buggie" to find the NICU Program Director "not very pleased I add" the MD was quite suggestive about some "rectal surgical procedure" the MD who was very astute legally and an ex FF stated that the officer could be charged and would be charged with "Obstruction of an Emergency Vehicle" if he did not place the driver under immediate arrest.... hey wait a second there doc that was ME! The look on the young officers face was PRICELESS but then again so was mine, I didn't relish the thought of being a pawn it this situation. The best part was when a (very hot in more ways than one RN) offered him a donut standard line (but we WERE packing them away like hungry wolves) the RN bent over sticking her a very well proportioned derriere in his face to reach for the box of goodies. lmfao. and just to answer any queries the RNs brought them from their Unit, Man she was hot did I say that already? At that the time the door was closed "Stat" and the officers face matched the color of his beacons. Well that was back in the day, I have not heard of a Police office pulling a rig over for quite some time in this area, no wonders here really if we are lit up, its not there bloody business what and where we are going, besides we have share the same contact number after all, give call my dispatcher a holler on 911. cheers

yea lets get back on topic fer a change, Rid your really old cuz kids these days use dont use capitalization or punctuation its not efficent the point of the correspondance was to gain info. the point i mak is this kid is judged by the form of his meesage you humiliated him as it is your MO under the bs guise of proffesionalism. i hope timmy and kyle dont go bak to macdonalds cus they get more respect there can you say ocd? that is all. period

Thank you Masta.

R/r, should you not have used a colon to start his list, unless the statement preceding the list could stand alone as a complete sentence? Are we having fun as of yet Professor?

Since the ratings of posts has now become a contentious issue for this demographic group I to would like to rate this one if the jury would be so tolerant; + 10 for support of peer and age group. + 3 for attempts at humour. (the correct way to spell this word) + 8 for International co-operation. gday mate, and btw wtf is soz.....dude. apologies to "MASTA" in advance.

Dear Bushy; AGREED! Is that internet Oz lingo? :twisted: Kyle + 5 for trying, my son is 14 and types just like you, I understood everything you asked...but then I am very old.

"If we live our lives continually motivated by anger and hatred, even our physical health deteriorates." -His Holiness the Dalai Lama Now those are words of wisdom and experiance. :!:

To DUST; Man you are so tolerant of idiots, but we can all learn from this tempered experienced attitude, you are fighting to care for those injured "hero's" dedicated to stop terrorism at a great cost personally, kudos. To REMT-Basic...a word of caution here....you mess foolishly with some who lives in a "Mobile Home" and you mess with the Whole Trailer Park.....apology is in order "STAT" to raise your status to one of respect! oh yes can you take a BP when small arms fire is aimed at you and some ass #@#$%@, has shouldered an RPG at your ass! I thought not! TRY AGAIN PLEASE! Late entry: When REMT-Basic has earned the respect of our very experianced practioners in this "ART of Pre Hospital Care" as Rid and Dust have with over 4000 insightful (bilaterally) and positive posts to boot, your input you may be respected, as for now don't bring a knife to a gunfight, put your super shears in your pocket your cutting yourself! That is ALL.....waiting!

Yea the best part is that it screws up nurses...OMG Im going to pay for that one!

OMG we just puled out the big guns...... put that scary thing away the little girls are screaming...like again! :shock: LMFAO! Sorry way off topic but this tread could go someplace good. Is the Military doing any research in the treatment of "Trauma" we learned a lot from NAM, and the Falkland's. :?:

Late Entry: I see that Rid is off line, I know that as a supporter of Bledsoe he would suggest a google search for the benefit of all. DR. B. Bledsoe, Handouts, Research for Dummies....it is most excellent power point.