AZCEP

S1 and S2??? I'm not familiar with those leads. Did you perhaps mean V1 and 2? It is not unusual for IC bleeds to have some ST depression, but the development of ST elevation would stand to reason. I've transported several with ST depression on their 12 lead ECG. Let's consider what the information tells us. What does ST elevation, or depression, indicate? +5 for presenting a topic that is frequently glossed over.

Sorry, but both items you mention are garbage. The CAP issues have been well covered already. The IOM is a fix for a problem that has already been managed. This device has no operational benefit to anyone. If you are allowed to use this device, you could use the King LT, or the LMA. Put a bell or whistle on something, or move the current one to a different place, and see how many people decide they have to have one. :roll:

I'd agree with you chbare. The quick axis determination from these leads would point to something other than VT, but we can't really rule it out with this strip. Shane made a number of good points in his post also. Seeing this rhythm at a slower rate would be very beneficial. A-fib, a-flutter, MAT, rate related BBB are all possibilities. We just can't know for sure from this strip. Amiodarone, Procainamide, maybe even a beta blocker would be useful to control the rate. Treating the shortness of breath angle might cause more problems though.

Apparently, I'm having some of the same image viewing issues you had in posting it. Is the rhythm regular? Is there any discernible irregularity with the R-R intervals? If the cardiologist has ruled out VT, what are some of the other options? There are only a couple that will meander around the 150 beats per minute range. How old was the patient? What was the rhythm when it was converted?

Having the LP12, you should be able to get the augmented leads to get a better idea of the axis. The rate of 156 is plenty fast to be VT. What did you use to treat it? Can you get the cardiologist to explain why this isn't VT to you? This isn't a cardiologist specific situation. If you don't treat the patient right, he doesn't get a chance to tell you you were wrong. What's the link to your myspace page?

The image isn't showing up. From the limb leads, you really can't tell anything.

Cardiogenic shock patients tend to be a bit hypovolemic, despite the presence of audible pulmonary edema. This does not absolutely indicate that there is enough fluid in the vascular system, just that the fluid that is there is beginning to leak into the pulmonary system. The patient that Asys described sounds typical of a tamponade, although through a different mechanism than trauma. Use judicious fluid boluses to maintain perfusion. The preload is the problem, not the ability of the heart to constrict, or the arterial blood pressure. This patient needs the fluid to fill the chambers of the heart so that the Frank-Starling mechanism can work.

The problem that I see with using the vasopressors (dopamine, epinephrine, Levophed) would be the effects they will have on the "constrictive" mechanism. Seems to me that the action you would want to have would be more ventricular filling, not a more forceful contraction of an empty chamber. Fluid boluses to maintain the pressure, and transport to a cardiac center that can do a pericardiocentesis would be the best option.

The Caroline text has led the rest of the paramedical education publishers into the realm of the graphic novel. Yes, it is simple and perhaps easy to understand, but it gives nothing to the reader in the way of usable information. Skip the paramedic text altogether. You can find better information from a 12th grade biology book. Pick up a copy of McCance and Huether's pathophysiology text. Much more useful than anything else you may think you need.

To further support ERDoc on this, firefighter523, do you know what percentage of MI's show no ECG changes? Before you answer consider that NTG is not the first line medication for an acute coronary syndrome. That honor is still held by oxygen. Even with the limited information that has been gathered to date, it is forseeable that NTG will be relegated to the scrap heap of history. If it is in fact worsening the ischemic area, why would we want to continue to use it? It can be of limited assistance, but it would appear that it is doing more damage than previously thought.

OH HELL. :x A semi-constructive thread regarding a common medical problem that affects a huge number of working Americans gone to crap because of the "volunteer vs. career" argument. :x :roll:

Check the articles I referenced. One of them seems to mention that NTG CAN cause ischemic tissue to receive less perfusion.

Actually, I got them from our friend Google. Using "NTG for AMI" as the search term.

So apparently, we use NTG to reduce the size of the injured tissue, which helps to limit the amount of myocardium that dies (infarcts). We are also helping to preserve cardiac function by reducing the preload into the left ventricle, reducing the workload.

A better suggestion would be to remove EMS from the fire service entirely, and have a separate EMS service being provided. Reduce the numbers of non-fire calls that the fire service responds to, increase the funding for EMS. Perhaps this would result in a recognition of the work that EMS does. This topic has been discussed ad nauseum, but continues to be brought back up. Please do a search of the subject. You will gain much information much quicker than forcing us to redo the entire thing.

Using "all" as a qualifier automatically means no. Some should probably have one done, but not every patient will need it done this way. Unless you are allowed to change the treatment you provide based on the temperature you get, it does not have to be rectal.

It would be nice if you included some differential thought process in this. A good many things can make you think ACS that do not respond favorably to your protocol Why do you stop with three NTG? Perhaps more importantly why do you include the patient's own in your count? If their medication does not give the desired effect, what use is it? Your maximum amount of morphine is 4 mg? How do you justify not using more than this? Manage their pain and blood pressure, not some archaic limitation that has been placed on you by a protocol that can't possibly fit the situation. Dual lumen IV's are a good consideration, but why two of them? The cath lab does not need this many sites for IV medications placed. If they do they will place a triple lumen central line. The dual lumens were intended for patients receiving fibrinolytics, not PCI. I can almost guarantee you that the cath lab does not "love" you, or anything about EMS. Your braggadocio of being "911 to open time" means nothing in the overall scheme of things. You need to have the patient revascularized in less time from the onset of symptoms, not from the time they call 9-1-1. A twelve lead is a good idea as an initial assessment for the cardiac presentation. The ASA can wait a full twenty-four hours and still be effective. The NTG needs to wait until you have gathered the information that it will be safe and effective. Too many situations can be made worse that don't need to. If you can get the entire list done that quickly then you are missing some steps, or taking some unnecessary shortcuts. Why do you need to call anyone to give NTG to an MI? You have already stated that you can give it without your 12 lead being done. Following the steps you've mentioned you give the NTG, watch the blood pressure plummet, then not refill the tank with fluid, then call for approval of a medication? Giving fluid to a right-sided MI will not "fluid overload" them. Do you realize how dependent the right ventricle is on preload? Do you understand how much fluid, and how fast you must give it, to cause failure? You will not increase the size of the infarct. I think we have found the problem with this one.

Yes, BEorP, that is roughly how long they are. Why people continue to hold their clock hours of education as a standard, when they are so woefully inadequate, remains a mystery to me. I've never liked the idea that a prehospital provider (paramedic specifically) can keep their certification/license with as little as 48 hours of CE. The information being gathered is just too much to allow this to be sufficient. It is impressive that to remain board certified, an ER doctor must have more continuing education than the bulk of prehospital providers get from their initial course. Maybe, just maybe, this is why EMS is the orphan of medicine. Could it also be why no one really knows who should be administering the rules for us?

EMT basics receive approximately 120 hours of instruction, including clinicals if required. This is not a basis for a discussion of medical treatments. Calling an EMT a medical provider is akin to saying a dishwasher is a chef. Both are important to the final product, but they are a long way from producing it.

The concerns are valid, but must be taken on a case by case basis. I'm also a Type I diabetic, and have been for a very long time. In 15 years of EMS, I've had two, count them two, episodes that caused a problem while on duty. One middle of the night hypoglycemic episode and didn't hear a page. Another, and August afternoon (~120 degrees ambient temp.) very lethargic. There are many ways to manage the situation that is concerning Dust and Mike. The easiest is to keep your BGL a bit higher than normal when you are on duty. Set your pump to a lower rate, or eat something every chance you get. Keeping food near by can work, but becomes pretty tedious fast. I may be a bit biased, but I would trust a diabetic that knows their situation as much or more than someone with any number of other medical conditions that a out there. If your doctor won't certify you to work in EMS, that is his perogative. You could seek protection under the Americans with Disabilities Act if you like the insides of courtrooms.

I notice that it hasn't been mentioned that ASA is able to be given within 24 hours of an ACS event, and still maintain efficacy. Earlier MAY be better, but there is no good reason to get overly excited about it.

My question is why do we need to study this to realize it? Deal with a specific patient population frequently, and they do better. How exactly is this newsworthy?

Did you not read your own post? The gastrointestinal tract is well suited to manage the makeup of a little sugar. After dealing with hydrochloric acid all day, this is nothing.

How would that information change the management of the situation at hand? WPW with a rapid response, tenuous stability at the moment following cardioversion, 5 minute transport to a receiving facility. Unless we make an unscheduled turn someplace, and the patient's condition worsens, there is no reason to be chasing down details that will not change our situation.