Camulos

As the general consensus seems to be that it is dumb to go into potentially hostile situations unarmed, please educate us with your wisdom on why it is not dumb oh learned SWAT / Army / ER hero. Just my $0.04 to add to this FORUM Stay safe, Camulos

Can you please tell me why Australia no longer recognizes abdominal thrusts? As stated by the Australian Resuscitation Council – "The ARC does not recommend the use of abdominal thrusts as there is considerable evidence of harm caused by this procedure". The "evidence" (if it can be referred to as that) by ILCOR in 2005 cites twenty two separate case reports of adverse events secondary to the abdominal thrust procedure. Some of the adverse events noted in this literature review included gastric rupture, abdominal aortic thrombosis, internal carotid artery dissection, mesenteric laceration, diaphragmatic hernia, pneumomediastinum, ruptured oesophagus and vomiting with subsequent aspiration. Although not specifically cited by the ARC as a reason to abolish abdominal thrusts it is interesting to note three studies that exhibit that higher airway pressures can be generated by using chest thrusts rather than abdominal thrusts. One was a randomised trial using cadavers and the other two were prospective studies utilising anaesthetised volunteers. Without an official statement by the ARC however one can only postulate whether these studies weighed into their decision making process on this topic. However being only three small studies I would think, or hope, not. Can you tell me when Australia did away with abdominal thrusts? February 2006 – Based on ILCOR recommendations from 2005. Can you tell me why a medic (if following the guidelines as written) would have to wait for the patient to decompensate before being able to assist if the back blows don't work and they don't lay down? The topic of chest thrusts did cause some confusion when first published. One misunderstanding here was the positioning of a casualty to be administered chest thrusts. As you seem to have been incorrectly informed it is NOT compulsory for the pt to be lying down to have chest thrusts administered. Lying down is one possibility however you have already highlighted the improbability of the pt cooperating with that approach. Therefore as it states in the ARC guidelines when referring to chest thrusts - "Children and adults may be treated in the sitting or standing position". Furthermore on the topic of chest thrusts the ARC states; "Chest thrusts are applied: • At the same point on the chest that is used when providing chest compressions during CPR. • They are delivered sharper and slower than chest compressions during CPR. In order to do chest thrusts you need to have the back of the patient supported. This can be achieved by either: • Placing your other hand on the patients back. • If the patient is sitting use your other hand to support the back of the chair. • Have someone stand behind to provide support. • Stand against a firm surface like a wall. • Lie the patient down. It is very hard to state categorically on how to achieve back support when using chest thrusts but the overall principle remains the same. Support the back any way you can. Remember if chest thrusts cannot be applied continue with back blows. If the patient becomes unconscious commence CPR." I have not touched on the role here of larnygoscopy and magills as I believe that would be a whole new topic in itself. I hope this helps and if you really want the actual references for any of the above just let me know. What an interesting post that is going to make – LOL. Stay safe, Camulos

I'm sure this was mentioned on the forums here not too long ago. Look up "Takotsubo cardiomyopathy" Hopefully what you were after. Stay safe, Camulos

I understand that is the point they were making and I still strongly believe that approach is WRONG!!!! Please tell me you check your pt's even if your monitor shows what are interpreting as VF/Asystole etc. I've seen VF looking rhythms that were caused by interference, I've seen asystole looking rhythms caused by leads falling off, in fact I've seen a whole host of spurious ECG rhythms caused by a multitude of factors. Whether you use "signs of life" or a pulse check, please check your pt's despite what the monitor may show. Come on, this is so basic!!!! Surely EMS has progressed beyond this??? Didn't I say exactly this in my second paragraph???? LOL Stay safe, Camulos

I hadn't heard of the rad 57 and thought the earlier supplied CO level was an air reading done by the fire dept which didn't tell me anything about the pt. I have since looked it up and must say "Can I have one please mummy?" - I love new toys. Would still like some comment on ? serotonin syndrome (SS) and whether that was actually investigated in hospital. I thought it may have been induced by opiates as was initially suspected by the EMS team. However I note urine tox screen was negative for opiates. Still does not rule out SS though as it can be caused by a combination of many other meds that pt's with a bipolar diagnosis may be on. Would be great to hear the end of the story if possible. Stay safe, Camulos

Don't know how useful this info is with protocol restrictions and all but you can use an 18G needle in a neonate in place of an I/O needle if necessary. This is commonly done in NICU according to my wife who is both NICU and PICU trained. I have no experience with this though and she has only ever seen it in hospital. Stay safe, Camulos

From a prehospital perspective there are many differential diagnoses here for me to even contemplate. Yeah let's get a BSL as that is easily reversible if it is the cause of the agitation. Apart from that I would restrain him. Physical restraint may make this situation worse hence my preference would be chemical in this case, high flow 02 with airway control if mandated, trip to ER and wish them luck. Given he was in a fire I would also have a low tolerance for sending him, and the other pt, to hospital due to the possibility of delayed onset pulmonary edema in such cases. I guess it's all about CYA. In hospital the management of this pt becomes a bit trickier. All the standard bloods, scans etc that these pt's usually mandate however the one thing I would want to rule out quick in this particular pt is serotonin syndrome - given the history of bipolar, agitation, recent admission with ? change of medications and the degree of hypertension. Mind you the clinical picture does not completely fit here as these pt's normally exhibit tachycardia and dilated pupils - neither of which this pt had. Temp may be a clue here also as these pt's can be profoundly hyperthermic. Would also be keen to know what this guy was cooking on the stove if we can determine that. Stay safe, Camulos

LOL I assumed catheters meant IVC's. Maybe not. He He Stay safe, Camulos

I'm sure you'll make a fine husband for the animals. Cya and stay safe, Camulos

I would be interested to hear your theory on why the glucometer was included. Stay safe, Camulos

I only need two things supplied which are essential to every shift - Doughnuts and a playboy magazine. LOL Seriously though I'm gunna choose; 1) PPE 2) O2 3) BVM 4) Defib / Monitor 5) Medication kit 6) Triangular bandages Perhaps it may be easier to just go to a different service!!! Stay safe, Camulos

Nah I still treat pt's 100% of the time. Those damn monitors are far too hard to cannulate and intubate for me to treat them effectively - LOL. Monitoring certainly dictates your treatment algorhythm during confirmed cardiac arrest. However should monitoring take over and negate pt assessment? I think not and believe that there is great danger in advocating there is "no point in doing pulse checks until you see an organised rhythm on the monitor" - as was suggested. In examining whether this approach is appropriate I would appreciate if anyone could answer this question. Are there any "disorganised" (your term, not mine) rhythms that can generate a pulse? Stay safe, Camulos

1) Evidence based research 2) Post it on emtcity.com and hope the EMS ppl run with it. Stay safe, Camulos

I certainly hope none of your ECG leads are inadvertantly dislodged without you noticing. I personally prefer to treat pt's rather than monitors. I question the validity of checking pulses during CPR to determine the effectiveness of cardiac compressions. During compressions the retrograde transmission of pressure through the venous system may give the perception of the palpation of pulses in the adjacent artery and may not be a sign of forward flow. This is the "venous pulse" that BEorP was referring too earlier. In that sense I don't know that checking for a "pulse" as a sign of adequate compressions is beneficial because I feel it is not clear what you are truly assessing. Stay safe, Camulos

There’s redness and then there’s redness. A small degree of redness may be considered normal and is usually localised to only a small diameter around the actual insertion site. Redness of this nature is not normally of cause for concern for me. In the original scenario however I note that the “leg was turning red”. Widespread redness covering an entire leg, or vast majority thereof, would definitely cause me concern as it would greatly raise the suspicion of fluid / drug extravasation. In a child this small, such extravasation can be devastating and could even result in loss of limb if large enough. It is also not uncommon for neonates to have clotting abnormalities. As I didn’t see it do you believe the redness could have been bleeding? Despite the actual cause, and even though there was a lack of associated swelling, I would be keen to get this line out ASAP. I doubt x-ray would offer me much in this situation. Even if the x-ray confirmed the line was in the correct position, I would still be keen to remove it due to the degree of redness described. I also note that the “I/O was firm”. In neonates you may not get the “firmness” that you would normally expect with older children and adults due to their relatively pliable bones. I have also found that IO lines typically run better under pressure. In neonates however we don’t run fluids in this manner as everything is syringed in so as to ensure accurate weight based doses. Lastly a question. Would re-aspiration of marrow be considered appropriate once fluid has been infused into this line? Stay safe, Camulos