itxtme

Wish I could "Thumbs Up" a moderator - nothing worst than intolerance, so your post may just give someone a little perspective!!

This is a completely different issue altogether. This is one of the times that you do what it takes to protect your patient.

I completely disagree; if you lie to a patient, you lie to them! I wonder if the OP's colleague has been taken out of context. I agree that there are times where the truth must be bent for the benefit of the pt. In those scenarios we all do it. There are degrees to the lies that you tell, and that is what VentMedic is getting at, but when a definitive benefit to the patient exists most health professionals tell the odd white lie to aid in the best outcome for their patient!!

I went to an adult patient that was (his words) "intoxicated with ice-cream" last night!! No costume though

Depends what you mean by "mental disibilities"

Over here we call it intellectually handicapped or IHC as grouping word; and this is not a derogatory term. That is assuming you dont mean someone with psychological problems in which case that is expressed quite differently..

itxtme, thank you for posting a well thought out post which included a journal reference (-5 though for, "I feel sorry for people living in your area."). I agree with you on one of your points. Which is the least of all evils, a heart that is pumping blood out of the body or a heart that isn't pumping at all? Without any scientific evidence to back it up, I'll take the pumping heart. Lost volume can be replaced and we can control the bleeding in many cases. Let's take a look at the article that you sited:

Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest.

Huber-Wagner S, Lefering R, Qvick M, Kay MV, Paffrath T, Mutschler W, Kanz KG; Working Group on Polytrauma of the German Trauma Society (DGU).

Klinikum der Universität München, Chirurgische Klinik und Poliklinik, Campus Innenstadt, Nussbaumstrasse 20, D-80336 München, Germany. stefan.huber@med.uni-muenchen.de

BACKGROUND: Resuscitation of traumatic cardiorespiratory arrest patients (TCRA) is generally associated with poor outcome, however some authors report survival rates of more than 10% in blunt trauma patients. The purpose of this investigation was to determine predictive factors for mortality in trauma patients having received external chest compressions (ECC). PATIENTS AND METHODS: Twenty thousand eight hundred and fifteen patients from the Trauma Registry of the German Trauma Society were analysed (mean ISS=24.0). Inclusion criteria were ISS>/=16 and available information on ECC either on-scene and/or during trauma room treatment. Included into the Trauma Registry were only patients with ECC and transportation into a hospital. Patients declared dead on-scene without transportation to a hospital were not recorded in the data base. A Logistic regression was performed to find out predictive factors for mortality. RESULTS: Ten thousand three hundred and fifty nine patients fulfilled the inclusion criteria. N=757 patients received ECC, 415 prehospital, 538 during trauma room (TR) treatment and 196 prehospital and in-hospital. Blunt trauma occurred in 93.2%, mean age was 40.3 and median ISS was 41.0. 23.2% of the patients were treated with a chest tube, 5.7% had a tension pneumothorax and 10.2% underwent emergency thoracotomy. The overall survival rate was 17.2%. 9.7% of the TCRA patients with ECC achieved good recovery or moderate disability (Glasgow outcome scale>/=4). Logistic regression showed thromboplastin time lower than 50% to be the strongest predictor for non-survival (OR 5.2, 95% CI 2.3-11.9), followed by massive blood transfusion of more than 10 units of packed red blood cells (OR 4.8, 95% CI 2.0-11.5), on-scene blood pressure of 0 (OR 4.3, 95% CI 1.6-11.3), age over 55 (OR 2.9, 95% CI 1.1-7.3), base excess lower than -8 (OR 2.7, 95% CI 1.2-5.9). The insertion of a chest tube on-scene could be detected as a factor significantly increasing the probability of survival (OR 0.3, 95% CI 0.13-0.8). CONCLUSIONS: Prehospital chest tube insertion was found to be a strong predictor for survival. On-scene chest decompression of TCRA patients is recommended in case of the decision to start with ECC. Based on our data, resuscitation after severe trauma seems to be more justified than the current guidelines state.

I have a few issues with this article (I will admit to reading only the above abstract). "Patients declared dead on-scene without transportation to a hospital were not recorded in the data base." I think this leads to a selection bias and skews the results. Was CPR attempted on these pts? If so they should have been included in the study. I realize that the authors are working with the databse they have available but it leaves out a potentially large and important population that should have been included in the study.

They have 415 people who suffered from TCRA in the prehospital setting. Did these people have a pulse/BP upon EMS arrival and then arrest during transport? If so they should be accounted for differently than people who were found to be in TCRA upon EMS arrival. I would hypothesize that if you compare the survival rates of these two groups you would see a much higher survival rate in the people who arrested in the ambulance versus the people who arrest prior to EMS arrival.

Here is another article from Annals in 2006:

Traumatic cardiac arrest: who are the survivors?

Lockey D, Crewdson K, Davies G.

London Helicopter Emergency Medical Service, Royal London Hospital, London, United Kingdom. djlockey@hotmail.com

STUDY OBJECTIVE: Survival from traumatic cardiac arrest is poor, and some consider resuscitation of this patient group futile. This study identified survival rates and characteristics of the survivors in a physician-led out-of-hospital trauma service. The results are discussed in relation to recent resuscitation guidelines. METHODS: A 10-year retrospective database review was conducted to identify trauma patients receiving out-of-hospital cardiopulmonary resuscitation. The primary outcome measure was survival to hospital discharge. RESULTS: Nine hundred nine patients had out-of-hospital cardiopulmonary resuscitation. Sixty-eight (7.5% [95% confidence interval 5.8% to 9.2%]) patients survived to hospital discharge. Six patients had isolated head injuries and 6 had cervical spine trauma. Eight underwent on-scene thoracotomy for penetrating chest trauma. Six patients recovered after decompression of tension pneumothorax. Thirty patients sustained asphyxial or hypoxic insults. Eleven patients appeared to have had "medical" cardiac arrests that occurred before and was usually the cause of their trauma. One patient survived hypovolemic cardiac arrest. Thirteen survivors breached recently published guidelines. CONCLUSION: The survival rates described are poor but comparable with (or better than) published survival rates for out-of-hospital cardiac arrest of any cause. Patients who arrest after hypoxic insults and those who undergo out-of-hospital thoracotomy after penetrating trauma have a higher chance of survival. Patients with hypovolemia as the primary cause of arrest rarely survive. Adherence to recently published guidelines may result in withholding resuscitation in a small number of patients who have a chance of survival.

It looks encouraging, but let's break it down a little. These were pts that were cared for by physicians in the field who were able to perform chest tubes and thoracotomies. In your (meaning all of the EMS providers on the site) practice, how often is this resource available to you? I think very few are able to have a doc come to their scene and crack a chest so this particular article is not relevant to your current practice. Again, this article does not discuss the differences in outcomes for pts who were in TCRA prior to EMS arrival versus those who arrested during transport.

As for the OP's question of ACLS for a traumatic arrest, keep in mind that ACLS guidelines are developed based on research involving medical cardiac arrests. They do not study traumatic arrests so it is impossible to say that the ACLS guidelines are appropriate/inappropriate in a trauatic arrest. However, we have nothing else to go on, so they are probably your best bet.

Thanks for the thorough reply ERdoc; I completely agree with the realities of traumatic arrest and what skills are realistically required to decrease mortality rates. My statement in regards to Diazepam618 was disappointment with the age old attitude that I hear see and live through (at my own service) with traumatic arrest, in that its futile so don’t bother!

Studies like this one provide insight into possible changes we could/need to make internationally in the prehospital environment if we want to get serious about improving decreasing mortality rates. Interesting what you are saying about ACLS drugs and lack of proven efficacy in traumatic arrests – this is one thing I certainly wasn’t aware of!

Where my two mentors disagreed was in the treatment of a hemorrhagic patient. One person says "ACLS drugs are just going to make him bleed faster" while the other says "treat with ACLS anyway". These are blanket statements of course.

So what do you do? Are there situations where you withold ACLS (let's say NSR / PEA with a ton of blood loss) ?

Your reversible causes for cardiac arrest include hypovalemia which is what the apperent problem is here. I have no idea why your mentor would think giving Adrenaline will lead to increased bleeding!? PEA is a loss of mechanical movement of the heart adrenaline looks to increase this to sustain a pulse. Yes given a pulse will lead to increased blood loss, however no pulse will lead to death....

Furthermore consider the pharmacokinetics of adrenaline. When given IV adrenaline has notiable effects on Beta and Alpha receptors. Specifically you want the effects of the ALpha receptor in regards to Systemic Vasoconstriction leading to "shunting" of blood back to the core of the body!

Once you have pulses it is a different story/ consideration and continued fluid resus and chrono/ino trophic drugs..

If it's traumatic why bother, there is a possibility that so much is going on within the body that you are a waisting your time without the use of hospital equipment, but if you must try to work it go with ACLS just to cover your ass, less liability that way your medical director will thank you.

I feel sorry for people living in your area. I suggest you do some further research on current Traumatic Arrest literature, you may be very suprised at people that may have lived if you had a different attitude..

Have a look at "Outcome in 757 severely injured patients with traumatic cardiorespiratory arrest." a 2007 article

Check to see if your current ones contain iron by using a magnet on them. If they do take a hax saw or something similar and saw off the pins. Go down to a badge shop and buy the high strength magnets to hold them in place

I know you said you didn't like the idea of standard ems jewelry, but the guy i was seeing when I passed my class gave me a 24k gold necklace of a star of life with my id number engraved on the back...

another nice idea is a good sturdy practical but nice looking watch.

http://www.citizenwatch.com/COA/English/de...mber=EW0620-52E

that's the watch that I have and is a good price, never needs batteries, and has really been durable with hospital and ems use.. and it's easy to decon if i get blood on it!

Good luck!

I have the boy version, great watches!!

Wow you must be really enjoying that trust factor in your relationship!!! I often work with the opposite sex overnight and can honestly say my partner has never been in the least bit concerned.. Talk to your wife about having a little trust!

Its the "almost always" part that throws you off because hyperventilation is commonly caused by stress and anxiety but not always. Answer C doesn't seem right because I believe a patient can hyperventilate from a head injury or diabetic emergency

ummm yes they do...

DKA (Diabetic ketoacidosis) is a form of metabolic acidosis which leads to a respiratory attempt at reducing this via blowing off CO2 (hyperventilating) as it is acidic. This breathing pattern is specifically known as Kussmaul breathing.

Head Injury is often found using Cushings triad. A triad of three baselines which indicate the injury. One of the three is irregular breathing which could manifest as hyperventilation.

So what exactly is the question. You should follow the patients management plan. You are not able to tell any more info in regards to the origin of this seizure. ie. is it another Pseudo?? So my advice would be to stand aside and state there is nothing you can offer. After all your only "involved" with EMS and this has no relevance on the care of this patient. Its like pulling a random person off the street and asking them what to do despite having instructions already!

You say Tonic Clonic seizures, now if these are Pseudo seizures generally there is no visible Tonic stage. The understanding of a Tonic phase is the mass contraction of mucles which generally causes back arching. This phase lasts only a few seconds and then the patient enters the clonic phase, thisis the rapid contraction and relaxation of muscles causing the typical seizure like activity. Pseudo seizures are usually clonic seizures only.

Signs of true seizures - (post seizure)

-Tachycardia

-Altered Level of Conciousness

-Lethargy

-Self injury (tongue biting etc.)

-Incontenince

amongest others..

If these are not present (or at least most of them) then reluctance must be placed on the validity of the seizure. Having said that without cerebral monitoring one cannot rule these out.

The question should be asked why you are being asked to intervene in what sounds like a fully developed Management Plan for the patient.

Do you feel there is a true danger to this patient? Then call somebody capable of assesing the pt - a paramedic

I'm not sure what to say about this age thing any more. Even if age isn't an indicator of your performance, you'll find that employers and patients tend to think so. People want someone who is at least in their mid-20's working on them when they call 911. They don't really care if its someone from One Tree Hill arresting the bad guy or putting out the flames but when they're sick or hurt, and someone is approaching them with a sharp object and a bag full of drugs, they don't want someone who can't grow a mustache answering the call.

Maybe its wrong. Maybe its unfair, but that is the way it is. So, if you want to stand in the middle of the street, and scream "Its not fair! I worked hard! I can do everything they can! I'm mature! I'm good!" and stomp your feet and throw yourself on the ground kicking and screaming, feel free.

I see what you are saying and you have merit in what you have said; but in my opinion if you have the maturity, the training and the clinical experience you will put the patients mind at ease. Age is irrelevant. You don’t choose the provider when they arrive at your doorstep and often like you say people judge the cover, but I can guarantee within arriving at hospital my patients have the utmost trust in me and my abilities. [early 20 year old]

anterior wall fascicular block small Q in lead 1 and possible prolonged qrs ??

left axis deviation (-40 to -90)

I have the axis as normal??? Dont tell me I have been doing it wrong all these years!

Cant see the Q wave either, but if it is there its certainley not big enough to be pathological!

Have dispersed clots travelled to his brain and heart?? Im going with AMI (inferior) - lets go with a V4R, )

Not impressed....

Really: Not impressed.

Far to expensive, doesn't seem like making anything better what I hate about the LP12.

We currently use the LP12 and I hate it.

In my part time job we use an Corpuls 3 (http://www.corpuls.com/en/konzept-concept.html.

I lov this one....Simply gives everything I need and the "divert it to parts with bluetooth" Idea works great.

Tried one of theose (Corpuls) and I have to say they unimpressed me. The biggest peeve was the lag with using the soft buttons, push it and get a response 3 seconds later!

I am quite confused at the thought that we need to with hold o2 to certain pt. I am not understanding this. i just spent over a week in Icu and then pcu on 02. As i see it i would not have been given o2 as far as your numbers and quotes. NO WAY !I can not go along with this.

I make myself aware of all the different studies out there to with holding o2 will benfit a pt. The AHA study and even the long studing from the Red Cross never give any reason. On a personal level of needing the o2, i needed it and maybe just maybe the fancy machines said everything looks fine, but i couldn't breath. With all the machines saying no o2, they trusted the pt and how it made you feel.

My biggest problem with all this is numbers rulling the pt not what the pt says that's living this. Listen to what your pt is saying not the book!! LISTEN LISTEN LISTEN to your pt!!!!

Ah and so the misinterpretation begins!! You need to read some of the source articles to fully understand just what Bledsoe is talking about in this article. I have just completed a review of this literature for my service and I will recommend some changes to things we do!

What Bledsoe is trying to get across is oxygenation is deemed of greatest importance in the pre-hospital arena and yet it is just a mere part of the equation. Look into some of the sources that have been referenced and I guarantee it will change your treatment techniques!!

I find it difficult to see why this would ever be Afib, the doctor that thought it was based on lead II soley suprises me. Anything could be causing interfernce on that lead, and the lack of disorganiztion in any of the other leads points towards a dodgy sticky, poor contact or limb movement.

Like the above poster I will underline why I think it is MAT and not Afib or sinus arrythmia

Decernable P waves before QRS complexes (against afib)

Multiple amplitudes and morphologies of the P Waves [they look differnt] (against sinus arrythmia)

For sinus arrythmia I would expect similar [same] shaped P waves in front of each QRS, this is just not the case in the strip. Somebody is right and the rest of us are wrong; wheres a cardiologist when you need one - maybe I should just mentions Nazi's and forfit the debate (godwins law for those who are confusedO.

It's not 3rd degree block because of the absence of any P waves. 3rd degree block will still produce P waves but they will be disassociated.

I dont see how you are saying there are no P waves.. I have circled some (not all) of the P waves, or what I consider to be P waves.

I would call this rhythm (the top one) First Degree AVB based on the prolonged PRI, however in the two complexes I compare there is no lengthining or any dropped P waves.

Maybe I am misinterpreting??

Given the patients history it would appear he is failing (CHF), the presentation to me (the first ecg) would make me query right sided MI given the bradycardia now exposed (in the ecg). MI protocol while treating the failure also..

Mine was when I was 2nd or 3rd shift on the ambulance and we were sent to a big guy with abdo pain. The medic gave 5mg and 5mg of morphine justifying his big stature; this seemed to get on top of the pain. While were driving down to hospital the pt appeared to look a little pale so I took his BP 83/70; hmmm I said to myself must be too many bumps in the road so I hit it again. The pt flakes out and I call the medic in, I had no idea what was going on!

Of course his BP caused the LOC and head down feet up sorted it out!! From this day on my first treatment for a decreased BP is positioning! I also believe that as a new medic you have to see some things at least once before you will fully recognize them in the field - to think how green I was

The occasional inverted p waves could still be MAT if the foci is low in the atrium and fires in upward direction first, correct? I'm blanking on the term.

No I do not believe so. In a PJC the the pacemaker is from junctional pacemakers, this firing heads upwards to the atria causing a either missing (hidden) p wave [as in the beat I have highlighted] but ultimatley it is below the atria. During MAT the starting point of the firing is still the atria so the firing doesnt need to head up per say to fire the atria.. Hope that makes sense.

As another aside apart from the missing P wave in the junctional beat you can see quite a differing pattern of the QRS (comparing to the other QRS complex's) indicating a significantly differing pace maker sight.

The fact of the matter is, you don't need to know anything in the prehospital setting, other than the fact that the person is having a STEM

I or not. Don't try to misinterpret me, follow your protocols for MONA and don't waste any time. There is no pt care that is more important than getting this pt to a cath lab. Additionally, even if the pt has no STEMI and s till having chest discomfort, they still may require intervention such as angiogram. I teach all EMTs how to recognize a STEMI and the reason why it is so important to get this pt to a cath lab.

There is something seriously wrong with this web page. Nothing personel but type doesn't stay in lines > ????

I disagree. 12 leads are average indicators of AMI (well maybe above average) but certainly not the gold standard. Step away from AMI's for a moment and a 12 lead is absolutely invaluable. For example we have a pt with possible CHF but differentials of double pneumonia we can use 12 leads such as axis deviation and R wave progression to help in choosing a more definite treatment plan. Merely a piece of the puzzle but if you use 12 leads for AMI recognition only you will have EMT's soon calling the cath lab for a LBBB (old onset) because they don’t know how to spot one (and we all know how ST elevated a LBBB appears!)

edit sp.

Just a point of order here: the term "spinal immobilization" is out the new PC term is "SMR= spinal motion restriction"

At least here where I am from anyway, thanks to Mr. Lawyer; apparently in a court case it went like this: "How can he be immobilized and still be able to move? So you lied!".

lol, thats ridiculous!! There is more than one way to interpret a statement. How can a car that has an immobilizer in it still be moved!? But I do like the sound of SMR, might pinch it

I remember doing some study on G6PD in pharmo and while I did not consider it originally it does make a lot sense. Of course being the case ethnicitys at risk include african american males, asian as well as arab individules

If he hasn't had any food in the last 48 hours, then his liver has used up the glycogen stores. The body has been turning to non-carb substances to convert to glucose (process called gluconeogenesis). EtOH impairs gluconeogenesis, leading to no glucose... ie this scenario. Treat it with oral carbs if the pt comes around enough to control his airway and can eat safely. If not oral, D50. He'll also need fluid resuscitatation. Thiamine is a great thought if you have it pre-hospital. EtOH-induced hypoglycemia does not respond to glucagon, although it wouldn't harm him either.

He may have been having PACs, brought on by the caffeine in Red Bull and No-Doz. That's an arrhythmia that will "fix itself."

I'm curious where the ethnicity/Muslim question came from... were you thinking G6PD deficiency?

I was thinking along the lines of you in regards to no food lately -> ramadan