OVeractiveBrain

AHA Currents had an article about induced hypothermia for improvement of post arrest cerebral function. Then, there were several articles published in Australia and Europe touting its success. Essentially, regardless of the arrest condition, induction of hypothermia improved patient outcome; people who would have died lived and people who would have lost significant function retained it. People walked out of the hospital. They werent wheeled by the new BLS crew to a nursing home, they walked out on their own two feet. The exact protocol used has yet to be identified. Many hospitals have initiated hypothermia protocols for inhospital arrests. Prehospital arrests (unfortunately for paramedics) show the smallest uses. This is mainly because medic trucks lack (1) an ability to adequately monitor core temperature (trans-esophageal or rectal monitoring), (2) specific equipment to induce hypothermia (refrigerated saline, circulation blankets, sometimes air conditioning all together), and (3) necessary pharmacologic intervention to prevent shivering (i.e. paralytics). The only identifiable benefit prehospital providers can provide is in the very beggining of initiating hypothermia. Ice packs on the neck groin and axilla can start the process, but it requires a hospital to manage them appropriately. Medics should NOT be inducing hypothermia unless there is an established hypothermia protocol at their destination hospital. IF A MEDIC STARTS COOLING THEN THE COOLING IS TERMINATED PRIOR TO TARGET TEMPERATURE OR TARGET 48 HR RANGE, THE PROGNOSIS IS POORER THAN WITHOUT HYPOTHERMIA In Hospital * Paralytics to prevent shivering * Water Circulating blankets, refrigerated saline, controlled air temperature * Core body temperature monitoring * Prophylactic antibiotics for infection prevention (increased risk when cold) * Control temperature for 24-48 hours at 28-32 C Results * Improved cardiac survival * Improved quality of life at discharge and at 5 years * reduced mortality in survivors at 1 year Prehospital * Lack equipment to adequately induce * Benefit of hospital hypothermia seen in patients without prehospital induction Protocol is great for patients, sucks for medics, and the EMS community will likely be the absolute last to have access to any of the useful protocols.

Simple explanation: The wave measures inspiration expiration. The wave goes up when you expire. At the end of an expiration you get an End-Tidal (tidal volume is the normal volume of gas that goes in and out of your lungs). It just so happens that there is no CO2 in the air. There is a lot of CO2 in your venous blood. Your body uses sugar and oxygen and makes CO2 and Water. The CO2 has got to be gotten rid of. About "45" (aka 45mmHg) of CO2 is in your venous blood when it gets to the lungs. 45 in the blood, 0 in the lungs, so CO2 leaves the blood into the lungs. When the person exhales, the CO2 comes out into the air, and another 0 CO2 breath is taken in to swap with the new blood. For reasons of chemistry, the diffusion of CO2 balances out (called "equilibrium") at about "40" (40mmHg, milimeters of mercury). If everythign is working out, bam, 40. So when you have an arrest, and you put a tube in, you KNOW its in the lungs if you get a wave. Up on exhale, down on inhale. If you were in the esophagus, there would be no change, and certainyl no wave. Wave = In. wave from 0 to 40 back down to 0 then up to 40 = greath ventilatory status. Their lungs are doing great. Their heart, blood, brain and kidneys might be toast, but their lungs are doing fine. Well what does it mean if it only goes up to 20? If you have a 0 to 20 to 0 to 20 waves going on with each breath, you are in the lungs. Your job is about done. Tubes in, tubes right, move em to the ICU. But what does 20 mean? It either means you hyperventilated a healthy patient (blowing off too much CO2) or their perfusion (heart and blood) is broken. Not your fault. if the CO2 is above 40 (which is likely post arrest), you are just realzing the effects of not breathing for a while. If you dont breathe, CO2 build up in your blood and your lungs. As you ventilate, and blow off the CO2, the wave should come back down to 40. What about high flow O2? What about it? Normal air has 0% CO2. 100% oxygen has 0% CO2. You still get an equilibrium near 40 on a healthy patient. End-Tidal Capnography measures the partial pressure of Carbon Dioxide in mixed expired air. It represents not only the concentration of Carbon dioxide in the blood of the patient being measured, but it also measures the amount of ventilation-perfusion ratio. Take Away: If you have an up-down-up-down wave, youre in the lungs. If you hit an up-down-up-down wave that goes from 0-40-0-40 and your patient isnt waking up, look to something else other than respiratory. If your wave CHANGES, and isnt flat on the bottom and flat on the top, start looking around the lungs - their airways are changing. Overactive

Im curious to hear what kind this is too, so im posting to bump the post to the top. Overactive

EMS is dispatched to a middle aged hispanic man for an unknown medical. Patient is a middle aged, 40 something hispanic male found in a hotel, where he works. Staff states they saw the man "drink something from his cart" and then "go unreponsive". The time course is not concrete, it sounds like earlier on (within the hour) was the drinking, now is altered mental. Medics interpreted "unresponsive" from the staff as "severely altered mental," since he is now a GCS of 6 and getting worse. Staff activated EMS immediately and phoned family who is present upon receipt of patient at the hospital. EMS arrival is within 10 nminutes of call, and to hospital in another 10. GCS: 6, Vitals are WNL (80, 120/70, good cap refill, sating 98%, breathing fine), lungs are clear, bowels are continent, sugar is 65. 12 Lead reveals no significant findings. at this point, the prehospital differential needs to be drawn. Deteriorating altered mental status moving towards 3, gag reflex intact. No hx, allergies of medications that anyone knows of. Possible toxic ingestion of an unknown fluid. What do you do? What do you think is wrong? Stop here and think about what you would do, what information you might like and where you would go with this. Your "trauma center/major med" hospital is 10 minutes away. The medics enroute administered narcan 0.8 IV, and have an amp of D50 (25g), 15LPM NRB. Differential was left at unknown altered mental secondary to toxic ingestion. In the ER assessment revealed a GCS of 3, one pupil may be enlarged (left 2.5, right 2), vital signs remained unchanged. No babinski. No other significant findings. Family is spanish speaking and small history is obtained. It seems that this man is middle-aged, works in the hotel, has no history, allergies, or medications. He has worked at this hotel (which is a fairly expensive one... its no motel 6, nor is it the W or the Ritz-Carlton) for some years, and it is his regular employment. Patient is induced and intubated, Chest X-ray reveals proper tube placement and clear lungs, no mediastinal shift, no abnormalities in lung fields or in axial skeleton. NG tube is placed and 20cc of fluid is removed. It appears to be gastric secretions of normal color. It is sent to pathology for analysis. A foley catheter is inserted and draws 250mL of urine, standard tox screen is negative. This all happens in 5 minutes. CT scan comes back with "diffuse edema, MRI ordered." I left my rotation prior to hearing what the path screen on the gastric contents was and no MRI was conducted on my way out. The doc on staff was pretty sure it was a CVA. I disagreed, but kept my mouth shut... she has the MD and about 10 years of experience in an ER on top of my 2.5 in a truck. So here is what I open for discussion: What do you do with an unknown altered mental that is rapidly deteriorating? Do you go for a "coma cocktail" or just perform monitoring of life signs. One doctor questioned the failure to intubate in the field (though they did have to induce the patient in the ER, so i can imagine it would have been challenging to tube in the field). This patient is as up in the air as can be. With the information given in teh field, what were your thoughts of a differential and treatment? Given the advanced techniques in the hospital, what are your thoughts on a differential and treatment? Does knowing what you know from the hospital encounter shift your differential from what you thought it could be in the field? Hopefully this will get you all thinking.

Medical School "Medical History Outline" CC / Hx FARCOLDER Frequency of Occurence Associated symptoms (CP + NV, SOB + Fatigue, Cough + Fever) Radiation Character of Symptoms ("whats it like?" i use "knife, fire or like an elephant") Onset ("When did you first notice it?" If they cant get anything "minutes, hours, days?") Location ("point to the pain" " Duration ("how long have you had it?" "each episode lasts x time") Exacerbating factors ("anything make it better?") Relieving Factors ("anything make it worse?") Time Course Expanded This is where stuff really changes. Prehospital medicine gives you about 15 minutes with your patient, not an hour. So here is where discresion comes in to play. For medicals, as a medic, I try to get the important things, listed in the previous post. Hx, All, Meds. You can ask things like travel, childhood diseases, or family history, but they are usually not relevant for prehospital medicine given your time limit. For CP or SOB i like to get a good social hx: Smoking, Drinking, Drugs, DM, Living environment (SOB and "diaphoresis" in an 108 degree house without A/C) and work. For cardiac events (CVA, ACS) family history is important. "Anyone else in your family ever have a heart condition? how about a stroke?" When getting the CC and FARCOLDER (i hate the pneumonic but its just an idea) you want to use OPEN questions. For Hx, All, Meds, especially with family history and social history, i use CLOSE questions. I want them to paint the picture of the current illness, but I do not want them to dominate the conversation with blibbery blab. I can conduct an interview in about 10 minutes, including the physical exam. I NEVER run through a pneumonic. Pausing to think of "which letter is next?" will make you sound incompetent. On a final note i was often very impressed with my preceptors. They knew just what to ask for every situation. They never seemed to ask more questions than was necessary. How did they do that? Well, they did that because they thought they knew the answer to what was wrong and got tunneled. In retrospect, even if they were right in their assumption, they often did a poor assessment. The nuance questions will come in time. You will know when to ask if there is a fever or if some one else in the house is sick or not, because you will have asked it 100 times. Of the 100 times, only 2 times will it have had relevance. You will then probably still ask it because it is ingrained in your thought process, but know that it doesnt matter except when you see that 2% again. As a beginner, you are going to fail. You dont know everything yet, and even when you graduate you still wont. Your skills develop perpetually over your career. In general, realize that there are about 500 questions you could ask each patient. Upon hearing the chief complaint and their history, you will have to decide which questions are relevant. You are not going to ask a trauma patient about their framingham scale (unless they suffered a heart attack resulting in the accident, of course), like you would not cinncinati some one with a fever from a nursing home (of course, there is always the chance of cavernus sinus thrombosis from an infection spread through the facial vein through the inferior opthalmic vein, incidence is about 1/100,000). At the same time, that doesnt mean you cant do a neuro exam on them to get a better picture of their condition, or even their general state of awareness. Good luck!

To answer the original question: (1) "whats wrong"? If something wrong, get the easy stuff: (2) Pain? (3) SOB? (4) N/V? OPQRST not bad. If bullshit: (2) Revert immediately to BLS. Hx, All, Meds is a freebie. "Any past medical history? Diagnoses (plural), Procedures or Surgeries?" "Do you take any medication?" "Are you allergic to any medications?" / "any medication you CANT take?" and WHY SAMPLE and acronyms are fine, but never hold them as rigid. They are just good guides to develop a picture. THe picture you want to paint is where did it come from, how is it now, and what should you do about it. On first approach, the "initial assessment": - Greet the patient to determine LOC - Put your hand on their wrist to take a pulse. Dont tell them youre doing it, and be gentle and subtle about it. Ive had some elderly patients take my hand, as though I were consoling them. Thats the gesture i make, and determine "strong/weak" and "slow,normal,fast" - Rule out critical stuff (CP, SOB, N/V) by asking closed questions (nursing style) Secondary Assessment (flushing it out) - OPQRST - SAMPLE - CP = Smoke? DM? Age? Pain scale? Inteventions - SOB = Smoke? Cold? Others Sick? Fever? -

Learning English grammar and syntax while taking the time to proofread helps to avoid law suits from poor documentation, regardless of your education.

I used two different types. In my more suburban job, we either handed off face to face with a log sheet (we carried ativan, morphine and versed). The narcs were sealed. If broken, they had to go back to the pharmacy at our local hospital (this was a community hospital). If we had no one to give them to at shift change, they went to the pharmacy or to a supervisor. At my urban service, seals were on the plastic box they came in. If broken, they had to be exchanged at the hospital that gave us our narcs. Drugs were given over to the supervisor "behind the window" at shift change, and again, were signed in and out. On the road it was up to us to take care of them. It was 100% acceptable and appropriate to take yourself offline to get your drugs refilled at the pharmacy Overactive

AS he said, no Hx of palsy, no exposure to infections that would present palsy, denies drug use

THen whats the question with the case? Positive Rhomberg test in a 40yo female without any contraindications to fibrinolytics is pretty clear cut. Head straight to the nearest ER and get her a CT scan. The only thing left is to determine an actual time course to see if fibrinolytics are viable. CVA/TIA is neuro. Cranial Nerve damage should be treated as a stroke until proven otherwise. Theres nothing in her hx, all, or meds to suggest theres anything else going on. Again, rapid changes in dosage of synthroid can lead to CVA / MI but would not simulate its symptoms.

Psych Hx? Past Medical History? Meds? Allergies? Sounds neuro to me. From what youve reported Id treat it like a stroke. Shes got + rhomberg findings and is hypertensive with tachycardia. A number of things could cause her to be excited which could cause the VS findings. That being synthroid. Though hyperthyroid, to my knowledge, does not include stroke like symptoms. It may have lead to a CVA, but should not mimic symptoms. I think you might not be letting on all your findings. I think what youre debating is whether or not this patient was really a psych or if she was having a cerebral event. With the data you reported, I would treat her as a stroke. If shes had these symptoms for 2 weeks (outside of 3 hrs), she could go to whatever hospital shed like: shes screwed anyway. But since that is unlikely, and shes got obvious symptoms, Id get her to the nearest hospital. If she is a stroke: She needs to settle down and determine when her symptoms actually started. If shes an acute, shes probably a good candidate for fibrinolytics (young, no hx, no surgeries). Ive brought in a drunk with ALS for a stroke, until we breathalized him at the ER at .350. But if they are presenting at all with stroke symptoms, treat it as a stroke. (btw, yes he smelled of alcohol, but he denied its use and it was 9am).

As always, my two cents. Hypothermia is the wave of the future. All ischemic injury is reduced by hypothermia. Whether its edema of a spinal cord or survival from a cerebral hemmorhage, hypothermia improves outcomes. Studies have shown it is effective to reduce ischemic damage, improve survival rates and neurologic outcomes of cardiac arrest (trauma and nontraumatic), spinal injuries (as in the case of the C4 fractured football player with national coverage), etc. Are you hurt? Are you going to lose tissue? Freeze em. Just make sure you sedate them first. Overactive

Connecticut may be strict as all hell about underage drinking, but thank god they are liberal when it comes to their medics. In New Haven, Yale-New Haven just swapped over to a "dont call us" policy. While you still CAN, theyd prefer you not, unless you have a full trauma (trauma with AMS) or a CVA mandating fibrinolytics (of which very few a actually do). It is amusing to walk through the door with a 79 year old female complaining of slurred speech that has resolved itself after a TIA a week ago and watch the nurse scream at you for not calling in a stroke team. That is, until teh doctor comes over and says "oh, ok. No, no Stroke Team." I get to look at the nurse with those "told you so" eyes. Owned. Here where I am in New Orleans they are moving towards New Haven Protocols. Everything is on standing order. In connecticut, the only thing I had to call for was administration of a benzo to sedate a combative patient. And even in that case I didnt HAVE to, the docs usual just sign when I get there. Most other benzo uses were standing. Only the Volley Services (Stratford, for example) which is a medic service, has to call for orders for everything. Adenosine? Call. Amio? Call. GLUCOSE? Call. Thats also the way Louisiana (especially New Orleans and the surrounding area) has been. Only now do they have standing orders for everything. Looks like i got down here just in time. I would probably take the 20 mg of Morphine and a couple 100 mg of lidocaine and inject myself if I had to call for everything. While I suppose if you developed your career under those conditions you would be used to it, I was (and am) very appreciative of services where they give the decision making skills to the paramedics, and let them make those calls.

Im sure its been said alot, but since this thread got bumped ill say it again. The AHA doesnt care if its providers know why they are doing certain things. Thats why you have paramedic school or medical school. The LEADER knows why; hes had additional training and education. What the AHA wants people to learn is how to perform. When the doctor says start a line and push epi, he doesnt care if the nurse/medic/resident knows why they are doing it, he doesnt even care what level they are, just that it gets done. The AHA recognized that adults learn better by seeing, repeating, and doing. Its the "jane fonda" workout tapes revolutionized for health care. By learning things like drug doses, sequence, closed communication loops, and team practice, they can ensure that all providers can then go into their own environments and adapt the simple skills to their setting. Do you have a phillips monitor or a wall-mounted paddle defibrillator? Who cares, you know what to charge at, and people know to stay away when shocking. Does your epi come in a pink box, blue box, ampule, or fire extinguisher? Who cares, the nurse will know how to draw it up, and the providers will know how much to give. The knowledge of how and why doesnt save people when faced with cardiac arrest. People working well as a team and doing what they need to does. Yes, there will be the MD some where in there who knows whats going on (sometimes not) but the point is really to get people to learn and use their skills. Go to medic / DO / MD / APRN / nursing / advanced medical professional school if you want to learn more. Personally, I hate not being educated. But the fundemental fact is that I can learn these things in other avenues. AHA teaches how to save lives in a code and recognize the signs and symptoms of stroke and ACS. overactive

Spinal tap, systemic angiogram, illiac lymph biopsy, and nerve conduction test. Just kidding. Hes got an adult (late onset) form of muscular dystrophy. Just to make sure, his face isnt droppy is it?t Like it is melting? Cause if it is, hes got about 2 years max to live. So far we've got Vitals, Meds, PMH, Allergies Focused Physical exam and History on the legs, and a bit on general appearence: Bilateral / Unilateral? Trauma/ Critical Event at onset? PMS present and quality? Range of motion? Pain with extension, flexion, rotation, or just when standing on them? General Appearence of legs, purple, swollen, edemic? Spastic Contractions? Limp? Numbness, Tingling, Pain in any other distal extremity? Also: His chief complaint is the leg pain, right? Nothing else? Bilateral DVTs in an active patient seems unlikely, and a lot of things can cause leg pain. Before I went down the OMG HES GOT DVTS AND IS GOING TO PE route, Id probably explore some neural stuff. In particular, the movement of pain from hands to the legs is peculiar, and strikes me as something systemic and neural. Though the fact that it moved from his hands to his quads throws out half my impressions. If it were mainly in his ankles it sounds neurodegenerative, since its in his legs probably not. While ODing on sympathetic agonists (like his puffer) could result in a diskinesia (feeling of needing to move around alot) actual pain shouldnt be felt. Especially since this guy is now at rest, and still has pain in his legs (i assume weve moved to the ambulance at this point, correct me if im wrong).