FL_Medic

really wouldn't have changed your treatment. Focal seizures are commonly missed and rarely prehospital. I don't think you were completely wrong thinking this presentation was a CVA. Which is worse? Missing a stroke, or missing a focal sz? 26 y/o, MI would be way in the back of my head. This is no where near as bad as mine! You guys are reaching. haha. Not bad though. If MS was given the medic should have been in the back in the first place. BLS before ALS though, a good thing to remember. Positioning is huge. That's why syncope patient's wake up after the tumble, haha.

We give Etomidate in our RSI but that's beside the point. He wouldn't have siezed if I would have just RSI'd him. The Narcan made him sieze. Read all the way through the post agin. You're right, if he would have initially presented with seizures though. I am not a get-the-tube medic, I rarely find a need to intubate most patients. I have a few criteria that one must meet to be intubated and risk for aspiration is one of them.

We can administer 5mg(2.5 in each nare) of versed IN via the MAD (which is great). If they are status Ativan would be administered after. I love the IN route, I don't know if it makes a difference but I always cover their mouth when I administer it, because I have had them cough, what seemed to be like a lot of fluid out at the same time of administration. IM is just as effective, but you have that big needle. Anytime you can eliminate the use of a sharp, why not?

My first call as a lone medic. BLS FD responded as well. Dispatch Notes: 25 y/o Male unresponsive. Breathing. Law enforcement on scene. Upon Arrival: 25 y/o male found sitting in recliner unresponsive with decreased respirations about 10/min. LE was on scene to arrest the indiviual for previous crime (grand theft). The patient was as is when they arrived. Unknown when the last time he was seen in a normal state. The patient was cool, pale, and diophoretic with dried emesis on his chest and around his mouth. An empty prescription bottle of Tramadol was found in a nearby bedroom. The patient failed to respond to verbal or painful stimuli. His initial blood pressure was 110/70 with a heart rate of 130. He was considered to be in compensatory shock. Opiate overdose was assumed due to his symptoms. No peripheral venous access was made after 2 failed attempts, and an external jugular vein was accessed. Narcan was chosen for administration to avoid having to intubate the patient (no back up medic on scene, hoping to just wake this dude up). Narcan was administered Slow IVP with a running line. The patient's respirations increased slightly and his O2 saturation improved (unsure of the actual percent). The patient began to display with abdominal contractions and the IVP was stopped. The patient presented with what appeared to be tremors, and was loaded up for transport. He did not regain consciousness, but frequently yawned in between "tremor episodes". In the Ambulance: just me back there Just as we left the residence the patient's oxygen saturation becan to drop with little increase in respiratory effort. His respirations decreased to about 8/min. BVM was applied to control the rate and depth with possitive increase in oxygentation. At this moment the patient began to decompensate and displayed with severe hypotension. A Dopamine infusion was set up in between ventilations and started. The patient continued to present with "tremors" and yawning. Arrival at the ED: ER RN states "Is he seizing?" ER Doc orders 10mg of Ativan This call opened my eyes. I don't know it all! The whole time the patient was displaying with tonic/clonic activity that the genius in me said was tremors. I researched Tramadol, learning that it has opiate properties but is considered a non-opiod analgesic. If Narcan is administered to this patient, seizures are a common side-effect. I learned that you can yawn while having a status episode. If I would have utilized our RSI protocol, the seizures wouldn't have been a problem, the airway would have been controlled, and I would have had a much easier time. Not to mention the obvious possibility of aspiration. Keep this in mind the next time you are treating a tramadol(Ultram) OD, learn from my huge mistake. They initially got the kids pressure up, and he suffered no perminant brain damage.

We have all had those calls that we wish we could have back. The first call that made you pucker up, and lose your ego. The call that you looked back on, realizing you missed something. When we have a call with an abnormal presentation, or just an interesting call we frequently research it after the fact. Some of us become near experts on a certain topic because of a bad or interesting call. Please use this thread (I hope there isn't like a whole section devoted to this already that I missed) to discuss these in a case review mannor. Be as specific as possible. Give a brief, but detailed history of the patient if you can, and maybe even some additional information you gathered after the call was said and done. If you wish, you may display the call without the treatment or diagnosis to get an idea of how other paramedics would respond. I will start this off with my next post and hope it sparks some good discussion. PLEASE, no rude or useless comments. No judgemental side discussions.

Attatched is something I put together for my organization. It's not a test, but good referance material based on your topic. I also included something I found on the net. ._DRUG_CALCULATIONS.doc ._drug_calcs.pdf DRUG_CALCULATIONS.doc

Actually the monitor diagnosis for Acute MI is pretty accurate if artifact is minimal. The rhythm diagnosis is, however, unreliable. If your have the Acute MI diagnosis, I would be very skeptical to say it wasn't. Although it is more likely to diagnose an MI when it is not one than it is to miss an AMI. If you see an MI and the monitor doesn't diagnose it, look again. I'm not saying it isn't, but it warrants a second look.

Good statement. When you have swelling to an extremity from an injury, what is used to treat it? I think with the future implementation of hypothermia, steroids won't be used for possible SCI anyhow.

gracias, that's the only difference? What's all the hoopla about?

Did you do your 12-lead before or after HR dropped? That rate could have caused ischemia itself, and if the doc had a patient with a low sinus tach, the elevation may not have been present. Also your nitrates could reversed ECG changes. My first thought though is that you had a patient with early repolarization. What monitor did you use? Did it diagnose ********Acute MI*********? With minimal artifact, modern monitors are pretty damn good at diagnosing AMI with ST-elevation > 1mm. With the changes you noted though, I would say you had a STEMI patient. We don't screen in the field, and even if we did, you should treat the same way initially. Maybe with the addition of a benzo. Cocaine can induce an MI, not a clot, but still warrants some O2, pain control, and vasodilation. Your treatment was dead on. Your question is a good one. Sometimes doctors (like paramedics) get one or two calls that present similarly and make there initial diagnosis without using diagnostic equipment. Not saying this is the case, but sounds like he made a pretty presumptuous comment.

My initial impulse is MAT. What is the difference between MAT and WAP?

I competed last year for the first time. It can be difficult because it is a game, and the scenarios can be a bit much. Just practice, and expect anything. Don't expect to beat the teams that always win... good luck.

LVH- Clinical Detection The unfortunate clinical reality is that the ECG is not very accurate as a diagnostic tool for determining chamber enlargement. Even in the best of hands, the sensitivity for detecting LVH (Left Ventricular Hypertrophy) does not exceed 60% (although specificity may approach 90 to 95% when certain criteria are met). Diagnostic accuracy for determining RVH (Right Ventricular Hypertrophy) and atrial enlargement is even less. Echo-cardiography is far superior to the ECG for diagnosing enlargement of any cardiac chamber. Simplified Criteria for Diagnosing LVH Deepest S wave in lead V1 or V2, plus tallest R wave in lead V5 or V6 > 35 and/or R wave in lead aVL > 12. Patient > 35 years old. Left ventricular (LV) "Strain" (see below). For adults 35 or over, remembering the numbers 35 and 12 allows diagnosis of LVH most of the time when it is possible to do so by 12-lead ECG. Only one of these criteria (35 or 12) need be met to diagnose LVH. These criteria are not valid for younger patients (under 35). If "strain" is present in addition to voltage the specificity (accuracy) for true LVH is greatly increased. Additional Voltage Criteria may occasionally be needed to diagnose LVH. We favor any of the following: An R wave > 20 in any inferior lead (II, III, or aVF). A deep S wave ( > 20-25) in lead V1 or lead V2. A tall R wave ( > 25) in lead V5. A tall R wave ( > 20) in lead V6. "Strain" is a pattern of asymmetric ST segment depression and T wave inversion (See Figure). LV strain is most commonly seen in one or more leads that look at the left ventricle (leads I, aVL, V4, V5, V6); less commonly it can be seen in inferior leads. If a strain equivalent pattern (See figure) occurs in association with voltage for LVH, specificity for true LVH is greatly enhanced compared to the voltage criteria alone. What if there is a conduction defect? (See LVH + BBB) Suspect LVH despite RBBB if the R in aVL is > 12, or the R wave in V5 or V6 is > 25. Suspect LVH despite LBBB or IVCD, if the S wave in V1, V2, or V3 is very deep ( > 30). It is probably best not to even bother trying to diagnose RVH when LBBB, RBBB, or IVCD is present.

Just an update on this, without my knowledge my agency has been planning on implementing induced hypothermia already. we are getting refridgerators for all our units and the local hospital system is on board. thanks.

It is actually a more important number than your systolic. Well, that is what I have been told by many docs, but it is difficult to apply it to your protocols if you have only systolic paramaters. The only time I have seen it used as a paramater in a EMS protocol is the hypothermia for ROSC which is the last topic I posted. Other than that I have not seen a medical director implement MAP as a starting/stopping point for any medications in the prehosital setting.

Thanks, Houston is the agency that I din't mention because I wasn't sure if they started the modality yet. I hope to see the research from there soon.

It's being done with cool NS. They are getting them down and the hospitals are keeping them cold. Vecuronium is used for the shivering, not true RSI. As the research is being done the bennifit is greatly outweighing the risk. It is being studied in the Neuro patients as well and has shown to reduce morbidity in the presence of CVA, but I haven't read much of the research on this modality for CVA quite yet.

Sorry, all of those are reversed, they must meet that criteria

I'm not using the protocol, so no. But the key is to keep the pt at 32-34 C watching their temperature while en route. Once at the hospital they keep them cool for 24 hours.

Yes, someone from Houston, I heard they are starting it there. If you come accross any research that can help me let me in on it. When did you guys start?

I don't know how many codes are averaged throughout the county daily, maybe 4-10. There is exclusion criteria for patients: Age > 16 Not obviously pregnant Temperature > 34 degreed C No pain response Intubated with ETCO2 > 20 There is no peak age in Wake EMS' protocol, but that may be something to look into as well as the obese patient. I personally wouldn't be telling the family member why they didn't recieve it, but it would probably be explained "he had a medical condition that contradicted the treatment". This should be a standard of care, and as many patients should recieve it as possible, it is not difficult logisticly or by skill. Our paramedics as you probably know are allready highly skilled and expected to know alot due to our progressive protocols. We would probably do it like we do all new training, teach it at a mandatory in service training and then test on it. Our transport times can be as much as 25 - 30 minutes on ground, less for post-arrest flying code 3 to the nearest facility, and we use air transport if the ship is available for post arrests. the prognosis is much better than without the hypothermia, that is the whole point of what I am doing. After researching this you can't honestly say you wouldn't want your loved one(God forbid) cold & FAST after regaining a pulse.

I don't know about the EMT course, but I have heard the paramedic course is overpriced for very little teaching. Good luck!

Actually Lee Memorial has baught out every hospital but 1 now, and the last one is where my medical director works. One hospital that I know of tried hypothermia briefly, but I'm not sure of the protocol they use. Neuro exam will be hard on the paralyzed patient. I think cath lab would be the one procedure that would be performed on these patients while they were still CHILLED. It is quite a project, but the outcome is well worth the work. We know what it's like bringing the prolonged arrest to the hospital after ROSC, they usually don't walk out, now could you imagine increasing the possibility of those true saves by that much?

I don't work in for this system, although my system is progressive.. I guess we missed the jump on this treatment. You are correct though, the hospitals in your system have to be in on it for the procedure to work. Wake EMS has supervisor vehicles (Expeditions I think) who respond to every cardiac arrest. In the supervisor's truck is a small cooler with NS in it. The pt is cooled with the NS via IV as soon as they regain a pulse. This method has shown the best pt outcome. I plan on speaking with my medical director myself after I organize all the research I can find. After I convince him I will be on the phone with every hospital to find out what can be done to get this rolling here in Lee County. I think if I really convince my MD & our protocol comittee we can work together on it.

I'm not... yet. Unfortunatly I just learned of this procedure last week.