Dispatched to 16 y/o F Unknown

[speedygodzilla]

I think he skirted the actual question with some sort of rebuttal. No the actual rational behind that specific comment.

The only think I can think he meant would have been 6lpm via NC or 15lpm via NRB.

But still, anything more then whats needed to keep the bag inflated is wasting O2.

Yes that is what I meant. And yes of course lower the o2 rate to keep the bag inflated. I didn't think I had to be that specific. We should all know the obvious. The reason for the short answer was A. I was just getting off work. and B. I figure and is more of a post and answer thing so I checked it when I got home. Going to sleep, when I figure that this is a call that will be on the posting for like a week. Did not expect my posting to get picked and tore apart. But hey it made me think, trying to figure out what needed rationale. Not even sure I know yet.

This is the longest 20minute call ever.

For me it seems this is way beyond BLS level. I would have to get ALS and leave it from there.

[spenac]

Yes that is what I meant. And yes of course lower the o2 rate to keep the bag inflated. I didn't think I had to be that specific. We should all know the obvious. The reason for the short answer was A. I was just getting off work. and B. I figure and is more of a post and answer thing so I checked it when I got home. Going to sleep, when I figure that this is a call that will be on the posting for like a week. Did not expect my posting to get picked and tore apart. But hey it made me think, trying to figure out what needed rationale. Not even sure I know yet.

This is the longest 20minute call ever.

For me it seems this is way beyond BLS level. I would have to get ALS and leave it from there.

What happens if ALS is not available? Can you think for yourself? In my part of the world basics often have to take vary serious patients the 90 miles to the hospital. Yes ALS should be there but don't become so reliant on it that you just do nothing. Again leave the box of comfort and stretch.

[Dustdevil]

Yes that is what I meant. And yes of course lower the o2 rate to keep the bag inflated. I didn't think I had to be that specific. We should all know the obvious.

It's not that obvious to many. If it were, I wouldn't have brought it up.

And the problem wasn't that you weren't specific enough. The problem was that you were too specific.

"Oxygen sufficient to maintain adequate O[sub:60b8887f32]2[/sub:60b8887f32] sats" is very non-specific, but would have been the perfect answer.

[CBEMT]

Yes that is what I meant. And yes of course lower the o2 rate to keep the bag inflated. I didn't think I had to be that specific. We should all know the obvious. The reason for the short answer was A. I was just getting off work. and B. I figure and is more of a post and answer thing so I checked it when I got home. Going to sleep, when I figure that this is a call that will be on the posting for like a week. Did not expect my posting to get picked and tore apart. But hey it made me think, trying to figure out what needed rationale. Not even sure I know yet.

This is the longest 20minute call ever.

For me it seems this is way beyond BLS level. I would have to get ALS and leave it from there.

My point was also that 2, 3, or 4 liters are also perfectly acceptable depending on the patient's condition.

Six or fifteen without thinking about it strikes me as the New Jersey/Los Angeles brand of BLS.

[speedygodzilla]

I do agree with you all. I was a bit short on 6 or 15lpm. The general impression he gave made me think either 6 or 15lpm due to "The child is in one-word-dyspnea. You ask her whats wrong and she responds, "can't"..... "breath"...."

I was taught in class not to treat the machine treat the patient. Just because the o2 sat is 100% doesn't mean the patient get no O2.

Looking back at the vitals of "Your EMT has a look at the pupils as you put on the pulse oximeter. Pupils are PPEARL and pulse ox reads 88%." I would put the patient on a NRB.

If I was out on this call on a BLS unit there is not much that I could do except O2, transport urgently (urgent to me does not mean reckless), Vitals every 5 minutes, go down the line with SAMPLE and do a detailed physical exam listening to lung sounds and so forth. Revisiting the initial assessment every 5 also. If calling for ALS was an option I would be sure to do it. While on my trip to hospital contacting medical control and letting them know the report, ETA and seeing if there anything they would like me to do.

I can do nothing more than try to calm and reassure her.

What more can a BLS do?

[Just Plain Ruff]

let's not get caught up in the fact that this is an ALS call as the scenario writer did a 12 lead and mentions iv and drugs.

I think that since the patient converted back into this rhythm again and we are 5 minutes out and the patient is not in acute distress now I'd notify the hospital that she's converted back and we are 5 mins out. Ask them what they want me to do. Maybe they have the cardiologists right there waiting, they have the OR waiting just in case they need to go and do whatever those cardiothoracic surgeons and cardiologists want to do.

If I know the physicians I work with, well enough, they are going to say "wait, don't give her anything else until we see her"

[AnthonyM83]

Yes that is what I meant. And yes of course lower the o2 rate to keep the bag inflated. I didn't think I had to be that specific. We should all know the obvious.

But it seems like you specifically say something different. You specifically say 6lpm NC or 15lpm NRB...as if it's one or the other...and you don't even pick one based on the info in the scenario?

[speedygodzilla]

But it seems like you specifically say something different. You specifically say 6lpm NC or 15lpm NRB...as if it's one or the other...and you don't even pick one based on the info in the scenario?

It was hard to say from the first general impression given. I wanted more info, which is why I also asked for base line vitals. Much easier to determine in real life. And yes I am the one making this decisions at times, even though I work an ER surrounded by RNs. They are not able to be with every patient that comes into what seems a nonstop ER at times.

[scope2776]

Would anyone consider adenosine for this patient? Or are you thinking more along the lines of an antidysrythmic?

Our class has been told numerous different things from different instructors regarding adenosine to patients with WPW. Some belive adenosine will cause circus reentry by shutting down the AV node, abet momentarily, and force the impulse through the accessory fiber. Others say that adenosine is the treatment of choice for WPW, because it will break the circus reentry by effecting the entire heart.

I know calcium channel blockers are contraindicated in WPW. Some claim because it forces the depolorization into the accessory fiber, and some claim adenosine is okay because of the short mechanism of action, but calcium channel blockers are contraindicated because they have a longer half-life.

[AZCEP]

The danger that calcium-channel and adenosine carry is exactly the same. The big difference is the duration of action of the two.

Adenosine will not break the circus re-entry, because WPW does not work under this mechanism. What it will do, just like the calcium-channel blocker of choice, is to slow conduction through the AV node. The accessory pathway will remain open, and willing to conduct every impulse around the AV into the ventricles at exceedingly fast rates. The ventricles will be unable to handle to barrage of stimuli, and VF will result. On the plus side, it will only last a few seconds, or a lifetime, depending on your perspective.

We already know that this is WPW with a rapid response. We should be well aware that adenosine will not be helpful for this situation. I'd agree with Ruff and suggest holding any specific medication and closely monitoring the patient for the short bit of transport that remains. A beta-blocker would be a good idea, but it won't be near as effective at converting the rhythm now that it has recurred. If we could have given one during the period it had slowed down, it would have been a good thing.