flightmedic608

Hello al;, I am glad that was such a straight forward and simple scenario. In further investigation, you would find that the patient has indeed taken some Prochlorperazine that her mother had in the cabinet. I hope that I was acurately able to describe the symptoms of a dystonic reaction. And although the preferred treatment would be Cogentin utilizing Benadryl in the pre-hospital may be effective. Besides the medication I have listed above, what other medication(s) are out there that may have this effect on a patient? Also what does EPS stand for? Next week I will attempt to put forth another interestng case.

Hello all here is weekly case #2. Hint - this weeks case will require some appropriate questions and investigation. On a separate note, there is not a possibility to obtain CEUs for case reviews without gaining approval number from every state. Case Presentation: 16 y/o female and her classmate leave school and drive to her house. During drive home, the patient states that she is starting to feel nauseous. Once arriving home the patient tells her friend that she has to use the bathroom for increased nausea and to see if her mom has any medication for nausea. Approximately 10 minutes she emerges from the bathroom stating she vomited once and had found some medication that she thinks is for nausea. About 25 minutes while doing homework the patients friend notices that the she does not seem to be acting correct, she appears as though her head is turned left and slightly upward, eyes midline to left deviation, her tongue appears to be continously darting in and out of her mouth and licking the top lip. She gets scared and calls 911....you arrive to find the below patient. Initial presentation: Awake sitting on sofa, slightly drooling from mouth. Head slightly flexed to left with an upward tilt. Neck muscles seem to be slightly protruded. PEARL, midline to left upward deviation. Upper extremities slightly flexed medial. When asked what her complaint is, the patient with some extertion states, (slightly slurred) that she cannot turn her head. Initial Vitals: HR 122, BP 104/78 RR 22 SpO2 100% PMH: None Allg: Unknown Disucssion points: What information do you feel you need, what differential diagnosis do you suspect , treatment thoughts, transport thoughts

No D, in many countries, including the US (certain areas) you are allowed to initiate CPR/ACLS then terminate based on your local guildleines/protocols. For example when I became a paramedic in 1994, I rode wtih NY EMS (before it as FDNY), and the arrest alogo was cpr, intubate, defib if nec, EPI, IV Isuprel then if no ROSC... end attempts. Pull IV and ETT and leave patient. (I cant remember if medical control was contacted or not, sorry was a long time ago) This makes sense based on the pure volume of arrests that they probably work in a 24 hour period, the taxing of your ED(s) would be immense.

I think we are all in agreement that as this case progressed, the decision making became increasingly difficult. I am always interested in others critical thinking on a patient who is truly an emergent one in the pre-hospital and hospital arena. I am grateful that I have had an opportunity to present a case that so many have been able to participate in, I hope that some have been able to take something from it. If people are still interested I will post another case on Sunday night. Is there any particular genre that people are interested in? medical vs trauma...adult vs pedi? Shoot me an pm or email and let me know what you are interested in reviewing.

Yeah, I’ll agree this case presents many challenges. I would weigh the benefit for the patient to divert by looking at every clinical aspect that I was presented with -- airway, blood pressure, seizure activity and the ability to continue transport safely. I dont ever base my decisions on if I will be "called onto the carpet" as you put it, I base my critical thinking on what is placed in front of me. I am a firm believer that with the sickest patient, the more hands and minds available the better for the patient. Please don’t confuse how I state the reasons for diverting as if I do not understand the physiology of this patients disease process. I make my clinical decisions based off of my experience in transport, what I have studied and what benefit each decision I make is going to be for the patient. I don’t consider any aspect of my clinical care to be super or ninja like, I attempt to give the most prudent and safe care that I can. This is a case that gives me pause, because I know that the patient needs tertiary OB care (most likely an emergent cesarean), but as the ALS provider you are at a crossroad when this patient takes a turn for the worse. My intentions of presenting case(s) are not for people to misinterpret my statements as anything other than being my thoughts and critical thinking. I present in a hope that we can all learn from each others practice (as a community), not to use words like super or ninja. I am not finsihed learning, nor will I ever be.

Sorry D, wasnt trying to not answer your question and it is valid. Personally, I will choose the most definative airway that I can place, usually RSI with oral ETT. My thoughts on airways adjuncts such as LMA, King etc is that they are secondary and although they have a place, they dont do well in transport (my personal experience and those of my peers etc) The LMA has great uses in the OR where gastric contents are usually known, and patients are being induced by an CRNA or an Anesthesiologist. I know there has been literature written about RSA with a known difficult airway and that may be a provider to provider choice. I would read any literature, take any class and practice as much as you can, so that you can make an informed decision. I hope this answers your question. I think Jinx had written that most secondary devices will be changed out, she is correct. Although that are a great secondary airway they are not definative.

Great post Asys, its hard to think or somethimes say outloud, but the fetus really is a secondary consideration with this case. Maternal well being = fetus well being period. Utilizing what medications most ALS unit have, starting Mg++ and benzos are your best route right now. Although I do suspect that most ALS units dont carry enough Mg++ to effectively cease her seizure activity. I also would quickly take the RSI path, hypoxia will be detrimental to both. My personal thoughts on community ED vs women/infants center is mixed, if I could successfully secure airway and begin ventilation, was well as decrease seizure activity I would continue to tertiary care. I think what a community hospital ED would give you would be access to airway management (if needed) and an expanded pharmacy to treat seizure activity, but would they be able to perform an emergent c-section if needed and what about neonatal resusciatation? Very difficult questions, I am glad this case has give opportunity for so much thought. J, I agree the best treatment for this patient would be delivery.

Interesting proposition. I would think that each provider would have to done his or her own airway assessment prior to begining tranport (i.e. Mallampatti, Lemon) and also go forward with their best clinical judgement. Personally, I consider LMA, surgical airway etc as second line in my difficult airway thought process.

My biggest thought about administration of any paralytic whether a intermediate or long acting would be that it would (1) cease the physical seizure manifestation, but (2) would not discontinue the neuro seizure activity. I believe that I would administer a short acting (such as succinycholine) to obtain airways control though, taking into account the difference that a pregnant female presents for airway management: Airway, Oxygen and RSI To avoid fetal hypoxia, use high-flow oxygen. In compromised respiratory settings, pregnant women have an increased tendency toward rapid development of hypoxemia. Anticipate higher potential for regurgitation of gastric contents and aspiration; thus, antiemetics and NG are strong considerations. Failed intubation is more common in pregnancy because of physiologic and anatomical changes that can lead to difficult intubation including:10 laryngeal edema from water retention lingual, nasal mucosa swelling from capillary engorgement increased facial adipose tissue affecting space for maneuvering laryngoscope handle increased abdominal contents elevating diaphragm with anterior shifting larynx morbid obesity (heavier than 300 pounds): mask ventilation may also be difficult due to increased intra-abdominal pressure and low chest compliance.11 Transplacental passage is insignificant at usual dose for intubation relaxation. If a paralytic agent is used, it crosses placenta in dose- dependent fashion and will cause fetal heart rate tracing to become non-reactive.12 Induction agents such as thiopental, propofol, and etomidate appear to have a positive benefit vs. risk when used in the critical setting for pregnant women This seizure complicates treatment because it is caused by a metabolic condition.

Interesting about not carrying Mg++, any thoughts on why? I agree with Midazolam, Lorazepam etc. One question if you plan to secure airway in this patient, are you concerned about the use of paralytics and if so why would you be? And I totally agree with the decision to transport to a woman/infants hospital. Hey J again great points, inline with what Kiwi stated. For discussion purposes, lets say the patient's DTR were between 3-4, (3 - increased but normal, 4 - markedly hyperactive with clonus). Mg++ administration great idea, and I agree with agressive pain management and BP managment.

Hey Mike what program do you work for? Yes Labetolol is one of the first line drugs given in an OB case like this, some OB protocols are based on a 20, 40, 60 mg escalating dose until BP is under control. This is an interesting case in regards to what each EMS has available and how they are allowed to practice with it.. Resp depression and hyptotension two concerns, as well as DTRs Fantastic follow up questions, breath sounds, clear and equal excursion. No dyspnea/increased WOB other than noted from being in her gestational state. Edema as noted, no notcturnal dyspnea. Urine output has been about the same throughout. I agree the headache should be addressed, by doing so you may have an effect on the blood pressure. My points of prority would be maternal well being: ABC (as normal), analgesia, sedation and BP management (working from with your ability). preparing for potential seizure activity. As you stated this case is difficult because you know she is ill, but which direction to take. I too would take the nice quiet ride to the womens center. I would most likely position the patient on her left side and provide a dark non stimulating atmosphere. Yeah Kiwi, I agree no role for helicopter, and when I present the cases I will do so based primarily on GR pre-hospital intervention. And I agree with your assessment that she is immed life threatening. Continuing the case.... Great posts so far, I think we are all in agreement that she is quite ill and needs tertiary maternal care. I am attempting to present cases that will focus on GR pre-hospital transport. Not GCCT or flight programs. That being said.......after starting transport, obtaining IV of crystalloid and providing IV analgesia, the patient begins to have tonic/clonic seizure activity.......you are now 35 mins away from womens center and 22 min from community hospital.

WIthout giving much away and telling the end result, nice thoughts on the differentials, no rebound tenderness just generalized tenderness upon palpation.... Lets say that its a weather day (and RW is not flying) which hospital would you choose? FHT upon ausculatation in 130-140s...no Nausea/Vomiting/Diarrhea (N/V/D)

Great start Mike and right on the money, although without a UA and protein etc its may just be considered PIH (pregnancy induced hypertension) First the tail number on that BK is N271NE... great thoughts on treatment, but most als systems in the US do not carry Labetolol or Hydralazine..what other choices do you think might be appropriate in this case? Nice thought on having Mag++ ready for administration...what are some of the side effect(s) that we would be careful to watch for during a 45 min GR transport? And yes BWH would be a great choice for care for this patient.... Very good questions D, lets say for a moment this patient is not aware of any issues with BP during first and second trimester. And if you scroll up I described how her edema presents. She is in the US, and has not recently traveled...and very nice catch on the quadrant tenderness, what other differentials can lead to having tenderness in all four quadrants? No N/V/D Hey Jinx, I emailed a friend of mine to see how he arranges ceu online for people, more to follow. Very good thoughts also, non stimulating transport very smart idea. In regards to the BP are you more concerned with the systolic of 172 or the MAP of 132? (MAP = SYS + DIA x 2 divided by 3), every system is different and our program focuses on the MAP instead of the systolic

There might be a way, I have to check on something. I know that some EMS web sites host CEUs for recert. Ill follow up and let you know.

Hello all, after being inactive a few years from being in school, I find myself having more time and access to sitting down and reading for enjoyment. If people are interested I will post a weekly case scenario, that I have personally been involved in the care of, reviewed at M&M rounds or have gotten premission to present in this forum. Please dont think that by presenting cases I feel as though I have nothing to learn, I present so that I may have an opportunity to continue learning. That being said here is Case #1, I will attmept to present straight forward as well as complicated cases.... Case Presentation: 17 yo f calls EMS with a complaint of with progressing vision loss and unbearable headache over the past day. She is a primigravid black female 28 3/7weeks gestation due for hospital/PCP exam tomorrow. Up to this point has had normal pregnancy and takes PNV. No significant past medical history and no family history of significant disorders or disease. Her major complaint is dioplia with bright light and loss of peripheral vision. Headache is rated as a 9/10 on a pain scale, which radiates to temporal region. No SROM, minimal contraction lasting 5 min at 15 min intervals throughout last four hours. Papillary edema, pitting x2 lower extremities. All quadrant tenderness. Initial Vitals: are as follows:RR 24 BP 172/113 HR 99 Temp 99, closest women's hospital is 45 min by gr, community hospital with no maternal services is 12 min by gr..... Disucssion points: Differential diagnosis, treatment thoughts, transport thought

Hi, without going into many aspects of physics...when you fly higher you decrease the total atmospheric pressure which means there are less molecules per breath at that altitude then at sea level. Example Pa at sea level is 765 torr and at 50,000 feet it is 84 torr.

It is interesting to read what others may have done when presented with this case. As you can imagine, we have tremendous peer review and discussed this at length. When I give airway lectures to local FD/EMS systems we discuss this case as a teaching tool. I strongly believe there is no right or wrong way to treat this patient. Each clinican has to understand his or her ability, resources and tool(s) that they can utilize. This case presents many challenges for a provider to work through; patient care, logistics, safety.

Great post Asys, something that we learn in flight physiology. Here is a table of something we learn called time of useful consciousness. Great information. This is without oxygen masks. Altitude in Flight level Time of Useful Consciousness Altitude in meters Altitude ifeet FL 150 30 min or more 4,572 m 15,000 FL 180 20 to 30 min 5,486 m 18,000 FL 220 5-10 min 6,705 m 22,000 FL 250 3 to 6 min 7,620 m 25,000 FL 280 2.5 to 3 mins 8,534 m 28,000 FL 300 1 to 3 mins 9,144 m 30,000 FL 350 30 sec tosec 10,668m 35,000 FL 400 15 to 20 sec 12,192m 40,000 FL 430 9 to 15 sec 13,106 m 43,000 FL 500 and above 6 to 9 sec 15,240 m 50,000

Hi, in regards to your post about suspected air embolism. It would not be a contraindication for HEMS, as Kiwi stated our cruise altitude would be between 1000-1500 feet. There are certain cases that you have to be concerned with pressure changes and altitude taking into account Boyle, Charles and Dalton Law(s) etc. Those type of flights would be primarily FW, where you could pressurize the cabin to your desired altitude. For example I recall flying (by FW) a 4 month with pulmonary complications who was vented at 800 agl, and had desaturations upon assent. We formulated a plan with the FW pilots to keep the cabin pressure at 1000 feet agl, and made some minor vent changes i.e. increasing FiO2 and were able to successfully transport patient while maintaining his saturations. Another thing we did during that transport was to replace the air in the cuff of his ETT with saline to ensure constant pressure. I hope this answers your question. Here is also a link to a relatively short article about air embolism. http://www.hboorcca....ir Embolism.pdf

Can you buy one of those in the states?

Bloke?,,,,,,,,I assume that means person lol. Yes, Kiwi and I know that my words are not allowing this wound the justice it deserves. It was not an easy decision we made to start down the airway algorithm, but we quickly wieghed options and made our decision. I think the best part of our decision making was the entire thought process of manually securing the airway with gloved hand and kelly clamps prior to attmepting to place an ETT. I think one of the largest worries we had, was the inability to BVM this patient if necessary. I am glad that the person I was working with at the time was someone I had been working with regularily for the two years prior, a lot is said for unspoken communication on scene.

Lol will ensure that I have a camera with me from this moment on with all flights. Yeah, the approach of placing a tube through the laceration was presented in M&M, many ideas were put forth and one we thought about, but looking that destruction to the tracheal structure we thought it would be best to stent the airway....I will leave the platysma question for others....hint its an important muscle.

I am enjoying the thought process on this case. This was definately one case that I wish I had pictures to present. I am not sure that I am clearly explaining how this patients wound presented. Imagine being in a cadaver lab, having access to the neck by a large laceration that transected the trachea and opening the neck so that the major vessels were exposed. The laceration to the trachea was wide enough that you could see into the tracheal rings. Asys, I understand the thought process you present about sealing the wound with an occlusive dressing, but it would not have been possibile. And the thought of NIVPP is a great one, but not only the concern of trying to stablize a very tenuous airway, we also had to take into account that the patient was a suicide attempt. HEMS has a very low threshold when transporting suicide patients who are awake. When we approached this patient as you can imagine, we discussed every aspect of the steps we were going to take, and we both agreed that stabilizing the trachea with external (sterile gloved hand and kelly clamps) was the safest route we had.

Hello all, very good suggestions, a couple of thoughts in regards to intubating through the wound. Please scroll up and note that the trachea itself is connected merely by 2 cm of cartilage, manipulation of the trachea or intubating through the trachea may detach the remaining 2 cm of tissue completely. This is a case where there can be many avenues to take, and I am interested in hearing potential thoughts. And just for understanding purposes we dont deny gr vs air transport based on suicidal intentions, we have a policy in place that crew safety is first period, meaning that we may exercise judgement to intubate patient just for transport purposes. I look forward to more thoughts on securing this patients airway,

I am glad that I had an opportunity to present a case that will allow discussion on airway management and the pharmacology associated with it. I agree there are numerous possibilities/solutions to this case. Like I stated in my initial post, there is not a right or wrong answer, I strongly believe in peer review and welcome the opportunity to learn from others.