HarryM

Well in the city where I work we have 4 ED hospitals within close proximity to each other and 3 of them are capable to dealing with critically ill patients and have ED's, ICU's, stroke teams, cath labs. So unless there was obvious major trauma (which only 1 hospital deals with) then go to the closest hospital by road.

Family are in the back with us and the patient. Seatbelt on of course. If a second family member then they ride up front or if the patient is sick and we are working on them in the back and don't want the family to see or get in the way.

Our service would code this as a "Green" priority which means anything coded Purple, Red or Orange would get priority over it. Green's have a KPI of ambulance arrival within 2 hours of the call. Maybe as it is the head it might be ProQA'd as a possibly dangerous body area and be an Orange which means it is a non-emergency dispatch but if the crew read the clinical notes from the call they can decide to upgrade to an emergency. I personally don't think it should be a lights and sirens job.

As per above (I also don't know what that BGL is): - NPA and bag mask to RR of 10/min = can we now get an SPO2? - Large bore IV access and push through 1L of NaCl = any change to BP or GCS with this? - 12 lead ECG = what does it show? - Naloxone 400mcg IV (worth a shot) - Scoop stretcher for extrication and go to hospital

We've just had a memo out from our clinical research team which has said that at the moment the evidence is against prehospital use of TXA, but that we will be taking part in trials ourselves and make a final decision from there. The rationale was that while studies did show TXA decreased mortality from trauma, the studies were conducted in countries that had much higher levels of trauma deaths than New Zealand. They applied the study results to NZ and found that as the rate of death from trauma was much lower here then TXA would have a lower efficacy and with a lower efficacy, the risks of pathological clotting are significantly increased which outweighs the possible benefits.

That's awesome. Trust me, it will lead to a lot less work immobilising a lot of patients and also increase comfort for your patients!

Hmmm you'd have to wonder why she is not paralysed and sedated if she is tubed. I'd start with some vecuronium and a midazolam infusion. Also maybe increase the NE infusion to maintain a systolic BP of 100. Also want to correct metabolite imbalances. The only fluid we carry is NaCl and I'm the first to admit that as this is the case I really don't have the knowledge to go an start talking about what electrolyte infusions she needs. Is there a toxicology screen/test available? Also be good to see results of a head CT? Therapeutic hypothermia is generally 32-34 degrees so she still has a way to go yet. Maybe once the vecuronium kicks in the lack of shivering will allow her temp to drop to that level. Otherwise consider cooled NaCl to help cooling enroute.

Also playing devil's advocate....does your system have nebulished brochodilators?

We never work an arrest if there are obvious signs of death. Generally almost never start a full resuscitation if initial rhythm is asystole. Of course there are exceptions, not a blanket rule.

Sounds tricky! No way that would happen here as our cops don't even carry guns! But am really impressed at Croakers' summary!

We use Suxamethonium for initial paralytic pre-intubation then Vecuronium post-intubation to maintain paralysis. Never seen or heard any problems with it. But again we only use it post-intubation and not pre-intubation. I'm not sure as to exact rationale of one over the other (not yet within my scope) but I do know that suxamethonium has shown to be superior over rocuronium when inducing paralysis for RSI.

As others have said, try and convince him to allow a quick ECG and taking of vitals and then if anything abnormal use that to try to convince him to come to hospital. Use his wife and call his GP and get them to try and convince him too. Then tell him he has a very high likelihood of dying today if he doesn't come to hospital. If that fails then document the shit out of it and leave him at home. He is competent to decline. If he goes unconscious then treat him as that is what the wife wants. If he had a fully written advanced directive and you can sight this then no treatment provided even if he does go unconscious.

We use it at BLS level (and above). With methoxyflurane and paracetamol being the only other pain relievers at a BLS level. We use it with a filter and mouthpiece, although you can also attach it to the same mask you'd use with BVM if required. From our clinical guidelines: Preparation: 50% NOS and 50% O2 Mechanism of action: Unclear but causes analgesia via CNS Indications: Moderate to severe pain Contraindications: Unable to obey commands, suspected pneumothorax, suspected bowel obstruction, SCUBA diving within last 24 hours, or has diving related emergency Relative Contras: Repeated use is associated with psychological dependence. bone marrow supression and neurological disorders. Patients with chronic pain syndromes who call an ambulance frequently are at high risk of developing adverse effects from repeated entonox administration and should be avoided in these patients. Onset: 2-5min Duration: 2-5min after stopped administration Common Adverse Effects: Sedation, euphoria, nausea, metallic taste, auditory disturbances Interactions: Increased effect when used with other analgesics or sedatives Notes: NOS expands gas filled spaces in the body, hence its many contras. Not contraindicated in patients with chest injuries but is if pneumothorax suspected. It should be discontinued if associated with worsening respiratory distress in chest injury patients. Not contraindicated for abdo pain but is for suspected bowel obstruction which most commonly presents with vomiting and abdominal discomfort. Abdominal distension and reduced frequency of bowel motions or passing of gas may be present.

Possibly may never give it. I've always had good relief with a properly done valsalva or spontaneous reversion. Our guidelines are to only give adenosine for SVT only if there is compromise or a hx of SVT responsive to Adenosine. It's specifically differentiated from A.Fib in our guidelines which is treated with Amiodarone. I'm not going to be the person to give Adenosine to someone in A.Fib and then have to explain it in an audit. I can use all the medical research in the world to prove a case that it was worth a try with a funky rhythym, but at the end of the day our guidelines are written by an intensivist and we follow them. We can go outside them provided we can prove we were correct. But as you say, you can't prove you were correct in a pre-hospital setting. If we revert the SVT with Adenosine we can leave the patient at home provided it's not their first SVT responsive to Adenosine.

Hmmm I'm not sure on that one. We use adenosine ONLY for SVT. You have to be 100% certain it is SVT. Otherwise for all other compromised tachydysrythmia's it's an amiodarone infusion and/or electric cardioversion for significant compromise. I'd be pretty wary of making a guess with any cardiac drug, but adenosine can be pretty nasty so personally I'd err on the side of caution and not go down that line unless certain it was SVT or consulted with clinical and got their view on the rhythm.