My First Code

[slo50stang]

Hey everyone,

I did not know where to post this, and this is my 2nd post, but I figure I'd share. (Mods, feel free to move this post if neccessary.)

I was riding today with the fire department as an internship with my school of which I'm almost complete, and participated in a Cardiac Red. My first true code, so I feel I should post my experience...

The call came out as Chest Pain, so we were on the way. It was a fairly long response time due to the fact we were far away from the call, which rarely happens in our city because we have quite a few stations in the area, but a recent structure fire pulled away some closer units.

About halfway there, the Lieutenant yells back at me "Get ready, we have a Cardiac Red", so obviously the scene had escalated. Now, I'm in the back, nervous as hell, because as a student, how else am I supposed to feel?

(Note: I'm a paramedic student, who does not work with EMS right now, so I have no outside experience other than school.)

We get to the scene, Engine Company is already there performing CPR, bagging with highflow O2 with a NPA, with monitor and pads connected, showing Coarse V-Fib. The Pt. had already been shocked once by the time we got there, and received one round of Epi 1:10000.

I also forgot to mention this is on a boat dock, about 300 feet from the trucks, so we hauled ass with the stretcher and backboard to get the Pt. on the truck as soon as we were ready. (Perfect spot to go down in Arrest, right?)

I took over CPR while the Engineer intubated. (Missed intubation, sunlight made it difficult for him. Retried intubation in the truck and was successful). Took out the tube after the first attempt and continued bagging. We gave the Pt. a second shock before heading to the truck.

Now we're in the truck, and we continue. CPR and start getting some more drugs prepared. Few minutes later we shock again, and I pulled out Lidocaine and calculated the dose, and pushed it. Here's where it gets difficult for me, so please throw in your input!

We had converted him into what looked like SVT, and the EKG confirmed, but the BPM was only at 160. All through school, we were taught that SVT is above 180 BPM's?

I hung a Lidocaine drip because that was the drug that helped us convert the Pt. , which the dosage based on our protocols is 2-4 mg/min. Can someone please help me figure out how to calculate the dosage based on drips? I nailed the Epi and Lidocaine dosages (although they're not too difficult to remember), but the drip had me wondering...

(With the Lidocaine, we also had a bag of NS hung, btw.)

We got him to the hospital, with his own pulse and respirations,but the monitor showed the SVT rhythm still... (Since we converted him, actually)

My question though, is would you have treated the SVT's? We learn to read the Pt. not the monitor so I can understand why we wouldn't treat SVT's, but I think any rhythm which the heart is beating in sync is a good result considering he was "circling the drain"??

I got a copy of the 12-Lead, so if you all want me to post that, I can, by the way.

I guess all in all, for a student, that's a pretty good call?

Ask any questions you feel neccessary, I'm sure I left out some details. It was a strenuous call for me, and it happened earlier today, so I'm sure I left out something

[lasen]

Sounds like a fairly decent experience for you first code so congrats on that.

In response to your questions:

1. I do not know where you are in your classes but if you haven't already, you will learn in ACLS to treat SVT as stable vs. unstable. That is determined using blood pressure. If there BP stays low and they have an altered level of consciousness, then ongoing treatment of SVT is indicated.

2. I remember the lido drip dosages using a very simple system. Lido is dosed in 1, 2, 3, or 4 mg/min. If you imagine the face of a clock placing the 1 next to the 3, the 2 next to the 6, the 3 next to the 9, and the 4 next to the 12 you can calculate your drip factor. The 3 on the clock is 15 minutes past the hour so the drip rate for 1mg would be 15/min. The 6 represtents 30 past the hour or 30 drips/min. The 9 is 45 past or 45 drips/min. The 12 is 60 or 60 drips/minute. This of course is using a 60cc drip set with your IV infusion.

Good luck in the rest of class and onward in your career.

-Lasen

[DwayneEMTP]

The twelve lead would be great. Try and post it in a size large enough that it can be read clearly, would you?

Lasen, great fourth post! I think there is some to be added, and I don't have time now (Yeah, I should be sleeping, NR in 8 hours) but it was very professional...and if you haven't noticed yet, you will soon, that we value professionalism very much here.

Thanks to both of you for your posts!

Dwayne

[slo50stang]

Ok, I have learned the "Lido Clock" once before. Thanks for the helpful tip!

I will post the 12-Lead if possible tomorrow!

Edit: His last recorded BP was sky high, (can't remember the exact numbers), and he was unresponsive throughout the whole transport, although he did begin to breath on his own (although very slow) upon entrance to the ED. We just helped with ventilations after that.

[AZCEP]

Nice job.

A couple of tips:

1. Leave fire department ranks out of a medical scenario. They really don't mean anything in relation to the care provided.

2. The SVT that you saw was probably generated by the epinephrine you administered. Leave it alone until the epi has worn off. Stability is determined by more than the blood pressure and level of consciousness. You will have to decide for yourself what makes a patient stable or unstable. There is a list of signs/symptoms to reference, but they don't necessarily correlate to how your patient is presenting.

3. The lidocaine clock is a good memory aid for where you are currently. Eventually you will realize that if you start it at 2 mg/min (30 gtt/min) and you continue to see ventricular ectopy, you can increase it. Helps to keep from developing toxicity in compromised circulatory status.

[slo50stang]

That was what we brought him back to...

Here's the 12-Lead

12 Lead reads SVT, but I'm leaning towards Sinus Tach. The rate isn't high enough, correct?

And yes, I figured the EPI is what made his HR elevated. That stuff can jumpstart a rock!

[AZCEP]

You don't identify a rhythm as SVT based on the ventricular rate. If you don't identify P-waves and it is a regular tachycardia, then it is reasonable to consider it SVT.

I'd still be willing to wait this out, and let some of the drug effects wear off.

[Dustdevil]

That was what we brought him back to...

Either in your profile, or below your posts, you are checking "Disable bbCode" which is causing your images to not show up. Go uncheck that for us, please.

[Asysin2leads]

I would really hesitate to call this a sinus rhythm. 158, in my mind, isn't quite fast enough to hide the p-waves as in a true SVT. The first tracing I would identify as a junctional tachycardia, but static EKG's were never my strong point.

[slo50stang]

It says BBCode is enabled, so I don't know how else to get the images to work. If you can guide me in the right direction, that would be appreciated