AZCEP

This method is becoming more and more popular prehospital. I would suppose there is a lower cost associated with carrying more pre-filled syringes than there is with a pre-mixed drip. If the providers can maintain the vigilence that is required to re-bolus when required, good alternative. If, however, the providers aren't to cogniscent of what time it is, this could get a bit hairy. I also like the fact that there is no evidence that neither Amiodarone or Lidocaine have been shown to be terribly effective at acute termination of Ventricular dysrhythmias, and they have identical survivability at one year. Anyone for drawing straws? Can't be any less effective, right?

Let's give this one the benefit of the doubt and say that there is a correlation between dirty equipment and increased patient mortality, and longer hospital stays, and more financial burden created. Let's even go one step further and say that this relationship only occurs in those patients we perform invasive procedures on. Let's, for a moment, completely eliminate the possibility that hospitals are breeding grounds for all manner of new, resistant bugs. MRSA anyone? Let's also eliminate the patient's residence as well. We all know that our clientele is not always the most hygenic of individuals, or they have difficulty getting to regular primary care facilities, so they call us. TB anyone? Now let's consider all of the other equipment in a transporting unit. How well was the gurney cleaned after that last patient? Did we make sure to disinfect the blood pressure cuff and stethoscope? No, that's okay we only used them once, and the patient had intact skin. What could they have possibly left for the next patient? I'd wager that should our patient successfully navigate this minefield of possible infection, the last thing they have to worry about is us inserting a less-than-optimally-cleaned laryngoscope blade into, quite possibly, the single most unsanitary orifice above their waist. Bang the drum GA, just pick the right drum next time.

Shtttpuppoesooeosleoi, woveoiww Acaoerraioea, watehekwetio, a dsfsnafweo;i akfdjwefjwoejoio... Oh, sorry checking the cleanliness of my laryngoscope blade. Guess I have to go clean it now. Shame on you Ace, wanting evidence to support a point made entirely on emotion.

Before establishing a barometer for others, we might want to take our own advice. I do mean everyone. Whit just made it so painfully clear. When you talk about how good a job you do, who exactly are you trying to impress?

My point was more directed toward the lack of using ventilation as an end point, not the sucess of ETI. Where it says the invasive airway is effective in reducing hyoxemia and increasing SpO2. It almost sounds like they see EtCO2 as an ETI assessment, instead of a ventilation assessment tool, but I could be misreading the data.

So the use of ventilatory management was able to reduce hypoxemia, and increase pulse oximetry, but no direct mention of ventilation. Pulse oximeters are notoriously garbage when it comes to useful clinical information, and have been well documented as such. Capnography gives real-time information about ventilatory status, and gets no specific mention of it's utility in this article.

Well, that was about as non-commital a response as we can hope to see. As patients get older, they have a harder time distinguishing and describing their symptoms, so it will be harder to justify a non-transport protocol. The PCI eligibility of patients still relies on the receiving facility being willing to support the decision that the paramedic is telling them needs to be made. Most physcians have a hard time with this. Whether it is a matter of ego, or disbelief, if they don't believe what we tell them, they won't speed up their decision making. Even worse, most cardiologists want to see the ECG, before they make a decision on what to do. That's your cue, Ace. I know you have the paramedic to cardiologist ECG fax study ready to fly. Before we get to that, it shows that when paramedics identify a PCI candidate, the faxed ECG will support that decision in most cases.

I'm going to have to find a new group to talk to about this material. The current group keeps looking at me sideways, like I'm talking about walking a fish. :roll: So I just retire to the City, and let it slide. Keep it up.

Amazing what a dedicated individual, with a few minutes of time and Google can put together. If this isn't a call for every student in the room to dust off their toolbar, I don't know what is.

Using the LEMON for the unconscious and the 3-3-2 rule for the semi-responsive makes life much easier, but why would we want to do that?:wink: Take every chance to assess an airway. Just like every other assessment you do, practice makes it a much more natural process. When the time comes that you need to decide how to secure an airway, it will be second nature for you.

Here's my small contribution http://www.mindspring.com/~divegeek/oxyconcern.htm I put the link in there because there are some pretty cool graphics that go with this, but I can't get them to show up in the quote. The tables look better in the original also.

Good information about acid-base imbalances in there as well.

Way to resuscitate a nearly dead thread Ace. Good stuff there, per usual.

This is vital information that every provider needs to have running through their mind when the time comes to secure/manage an airway. While reading the information is good, the combination of the book with the course that goes with it, is invaluable. Take the opportunity when it comes to your area and lay out the money to attend. The SLAM conference in Dallas is another excellent resource. If you are in the Dallas area in April/May, you will not find a better way to spend some time making yourself better at something your patients can't live without.

It can be used that way, but often it will be used to compare to previous ECG's. Which we always have available prehospital, right? :wink: An early obtained 12 lead can help to guide what treatment is doing, and what treatment should be tried. As we go through the MONA diatribe, if we see changes to the ECG with the relief of pain, then we can consider changing our steps a bit. If we don't do a twelve lead, we can't determine the changes as easily, and we will continue down the protocol without doing much thinking for what is happening. Great question by the way.

It is a bit of an extrapolation of what you are already using it for, but not too tough to figure. If the patient has a pacemaker, and for some reason you think it is not being effective. Be it rate, contraction of the heart, reduced cardiac output, will all show as changes to the size of the waveform. If you see a EtCO2 value that is less than what you know should be normal, you need to start looking for a cause. Cardiac arrest is the easiest to see this happen in. Initial values should be close to normal, because the CO2 gets trapped in the hypopharynx. Then, in short order, the value drops as you ventilate and blood doesn't return to the lungs as well. When your CPR is effective, you will get a steep increase in the amount of CO2 that is picked up. More blood returning from the periphery, wouldn't you know. As your compressor gets tired, the CO2 value drops. Change rescuers, CO2 increases. On the ROSC, the CO2 should increase as well, and has been shown to indicate better long term survival. Very good stuff, and so easy to use I commonly tell my BLS colleagues to use it.

30-35 minute soak in bacteriocidal/virucidal/tuberculocidal solution following the recommendations of the manufacturer. The next time I see someone with a sterile mouth, I will worry about how clean my laryngoscope blade is. By the way Dust, isn't sand blasting the suggested method for removing contaminants from most equipment? Stay safe.

You are right commodore, and interesting point to make. Please work on the grammar so we can all better understand what you are trying to communicate. Just a suggestion.

The most useful thing I've found from a pocket reference is the prescription drug list, and that is why I would recommend an easily updated electronic version over one that you have to buy a new one every few years. The drugs are being introduced daily in such numbers it is near impossible to keep some of them straight. The interactions of the new with what we carry is one of my concerns, so the updates are easily available. I agree with Dust's suggestion not to buy one to use because you don't know how to do an assessment, or can't remember which questions to ask when. Learn those things so you can do them in your sleep. Someday you may have to.

This is some timely information, with the number of CHF related threads going on. Atta Boy Ace! Perhaps the clinician should take into consideration the wide range of possible responses that a medication can cause, shouldn't they? I guess that pathophysiology stuff is pretty important.

GA, You will have to give us better responses than that. There is no way that the only assessment your medics are using is the blood pressure to determine the presence of CHF. The list of differential's is just too long. I mentioned a couple in a previous post, but you and I both know that was merely the tip of the proverbial iceberg. Blood pressure + JVD-->good possibility Blood pressure + JVD + lung sounds--> even better Blood pressure + JVD + lung sounds + Pt. history-->better still Blood pressure + JVD + lung sounds + Pt. history + Fulminant-->slam dunk Each step along the way the picture becomes more and more clear, but you can not determine the problem with an individual vital sign. Not even the utility of capnography can eliminate all of the possibilities. A BNP test from a lab, narrows things down, but you have to use it with all of the other clinical information. I will admit, that if your crews are on the fence between CHF and cardiogenic shock, then yes, the distinction is made from the blood pressure. Otherwise, your argument is full of holes.

To tie into Ace's last post, great information by the way, we've made it semi-policy that any patient receiving medications, or with complaints above the waist, have EtCO2 documented on them. The waveform makes it that much easier to justify what needs/doesn't need to be done. The receiving faciltiies look rather puzzled when I explain to them the capnography is to monitor ventilation, not oxygenation.

There are a number of better choices than Dobutamine for CHF. Milrinone(Primacor) for one will increase the contractility while at the same time causing mild vasodilation without the tachycardic response from Dobutamine. NTG is still the treatment of choice for confirmed pulmonary edema, but the problem lies in confirming it. The biggest issue is determining what the problem is. Is it truly pulmonary edema? Is it pneumonia, that is moving enough air to sound like coarse pulmonary edema? Is it in fact cardiac asthma? Too many possibilities to say that the blood pressure will make the determination. If it could, don't you think someone would have used that method already? Blood pressure will guide treatment, but it does little to tell you what you are dealing with.

Isn't this the same type of set up that the AHA used when studying Amiodarone for cardiac arrest in 2000? If the manufacturer of the device donates the equipment, how can there not be a conflict of interest by those gathering the data? Interesting idea, but I doubt 89 patients will create a desire to change current practice guidelines.

Another good reason to limit the amount of medications a Basic provider can administer.