RSI Posted April 11, 2013 Share Posted April 11, 2013 (edited) Another consideration is the fact that we have a patient experiencing significant tachycardia and significant instability. When faced with this situation, how much time are we going to take to ask and answer incredibly detailed questions? Just to recap the information provided: From the door Patient mentation: Altered/Unresponsive. Cyanotic around lips/peripherals Eyes open. RR - Shallow, labored, 35/min Pulse - Fast, weak. Obese Hx COPD/CHF "Okay" yesterday (HAHA, what does that even mean? Talking, conversing, aware? Or in the same exact unresponsive state sans SOB - I'm going to assume the former) Diagnostics EKG: Narrow Complex Tachycardia - 210 BPM; No P-Waves BP: 84/58 SPO2: 85% LS: Rales in all fields I think that's it? I'm coming late to the party but from what I've gathered, we're on the brink of cardioversion. And chbare brings up an excellent point. You don't have a lot of time. Interventions (~2-4 min with 2 ALS crew members?) O2 via NRB -> BVM IV - with blood glucose from the stylet; NS flowing @ < WO. Monitor - 4 Lead Cardioversion Prep Physical Assessment: Eyes PEARL? Smell of urine/feces? Sores on her body? Edema? Abdomen palpation - soft/hard? Assessment Questions (during interventions) What is she in rehab for? What is this patient's baseline mentation? Why is she not on oxygen? What has this patient's trends been in rehab? Improvement or deterioration? Increasing complaints of SOB during her stay or sudden onset in the last 6 hours? Any other complaints? Bed-ridden or active? Paperwork history: Recent infection, surgery? Pertinent meds - Antibiotics, Anti-Coagulants, Antiarrhythmics? Ddx Infection (sepsis), Stroke, Hypoglycemia, Hypovolemia (internal bleeding), Overdose, PE, CHF/COPD. While it's easy for me to say I'm shying away from immediate cardioversion, I'm sitting at my kitchen table nursing a caffeine headache in shorts and a t-shirt. On-scene would probably be a different story. I feel like an immediate cardioversion may convert her rhythm to NSR only to revert back to its narrow complex tachycardia (which I'm going to assume is SVT). So with my assessment questions in hand, I can cross off quite a bit of my differentials as I package. Assuming none of these questions are answered: TX Cardiovert; -> No response, package. (If there is a response, stop here). I feel like cardioversion is an appropriate, valid response. But I don't believe it will solve the problem (with the information available). Grab a nurse or a third responding crew member En route: BVM (followed by RSI), 12-LEAD. On-scene time: 10-15 minutes; Transport time: 10 minutes; Total elapsed time: 20-25 minutes. I'm a new, green medic. If this is inappropriate or VERY inappropriate, please tell me. I'm still in the midst of being trained. I'm working on my prioritizing my assessments so any feedback would be appreciated. And whoever thought of the auto-saving feature on this forum, you're awesome. Edited April 11, 2013 by RSI 4 Link to comment Share on other sites More sharing options...
DwayneEMTP Posted April 11, 2013 Share Posted April 11, 2013 Inappropriate? That's the most awesome friggin' post that I've seen in the last year!! +2 I believe that it's way past time to cardiovert this patient. I'm not confident that it's going to stick, but perhaps we can temporarily salvage some perfusion value? Doc, you say that you would want more info before doing so...what info might you get that would likely change your mind? Link to comment Share on other sites More sharing options...
ERDoc Posted April 11, 2013 Share Posted April 11, 2013 Nothing in particular, I'd just like to get as much info about the pt hx as we can while we are setting up. I would not hold on the cardioversion. Link to comment Share on other sites More sharing options...
DwayneEMTP Posted April 11, 2013 Share Posted April 11, 2013 Ahhh....gotcha... Link to comment Share on other sites More sharing options...
Paramedicacher Posted July 21, 2013 Share Posted July 21, 2013 I always call for additional support the second I see an obese patient. I need this job for a long time but I need my back longer. Raise the head of the bed and evaluate your ABC's. I would want to bag her and assist vent with OPA if she doesn't gag ( which is a good indicator of LOC as well). Rehab facilities give pain meds so I'd be worried about OD's right off the bat. Send a man to get some staff with info. Check pupils while we get vitals. Package this lady as best you can before help arrives. Monitor, rhythm, IV, fluids TKO. Base contact and get her out of there. ALS drugs, if needed, on the way. Link to comment Share on other sites More sharing options...
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