DartmouthDave

Hello, I liked the blood set for the Medsystem III. It is quite helpful when giving lots of blood. Sorry, I am not following you 100%. I think you are suggesting connecting a gravity blood set to the half-set (the one you connect the syringe to). If so, where I work we do that from time to time. No issues at all. Just not as tidy. All the best, David

Hello, I have attached a YouTube link showing the challenges of a status patient in the field (starts around the 2:15 mark). Interesting stuff. All the best, David

Hello, I agree Matt, outside the hospital, things are more worrisome with many unknown factors. In fact, in most cases, the etiology of the seizures is unknown and airway protection is a great idea. Especially, in the case of a TBI, SAH, and so forth. As opposed to a 'neurology' consult with a chart and background information. In fact, many difficult to manage seizure patients (if local) are know by the neurology service. I was referring to the approach outlined by the authors and not critiquing ED seizure management at all. Again, it is better to have a secured airway in most situations. Cheers

Hello, I have attached a link to a outstanding review article from BRAIN: JOURNAL OF NEUROLOGY on the management of status epilepticus. Very helpful information. Also, if you look at their step approach they are much more cautious than one typically see in emergency medicine (i.e. three+ seizures without recovery is status). More time is given for medications to work before intubation and general anesthesia. The treatment of super-refractory status epilepticus: a critical review of available therapies and a clinical treatment protocol http://oup.silverchair-cdn.com/oup/backfile/Content_public/Journal/brain/134/10/10.1093/brain/awr215/2/awr215.pdf?Expires=1485878433&Signature=EYWaFW2VPwjf75aa7W90l-zxtW~X2vCN5dh0wnuXw1SgIo7wor2U3CZ75HwaPiUX5QyfF4uN0tzJlVUFYsGtr8XelQ5JbPfy7l55Gz~xqy1TXE4g1lap8KQjNGicehxghlAq6P3BP0jQ22ZD-lJnaCLJt8nxTMDMDrAvBnbrs5I72AhtoFQs8cTFuHcgCNmgTROXIpUf9FnxJfZMtnNU6raI3gl1HB2BVGYrlFeX6gZZze3Wthk~cuQqSoQTCAPMegLPzQIR9MnGXXyc2OWA~a6IwbC2dKBywvIbnQ-V8EMCK7sh0CEa~ovWSosPHINRPHgnOTn4CutQfd0LLjhz4A__&Key-Pair-Id=APKAIUCZBIA4LVPAVW3Q

Hello, I have been with Medavie for the past 5 years now. Sometimes, I still miss the great white North. K

Hello, Very interesting. In my region, as far I know, ECMO has not been used for out-of-hospital cardiac arrests. Off Label, in the case with the young women and the PE, did they try fibrinolysis first? Cheers

Hello, We use backpacks: an airway bag, a ventilator bag, a circulation bag (IV pumps, ect..) and a drug bag. Scene calls we use the airway and drug bag. ICU transfers we haul in the lot in. Also, we use the LP12 (soon Zoll) and it has compartments on the back and side for BP cuffs, EKG cables, and various cables to fit different arterial line. http://www.ehslifeflight.ca/indicationsfortransport/ADULT/Pages/default.aspx The ventilator, pumps, and LP12 all attach to our stretcher which we can transfer between fixed wing, helicopter, or ambulances. We use to use a #9 and tray but now we can load the stretcher into a King Air: http://www.provincialaerospace.com/SurveillanceSpecialists/MedivacAircraft/ Downside with the bags is keeping them dry in winter. Lay them in the snow and they get wet. Or, getting blood on them. Lastly, equipment takes more abuse in a backpack. Cheers

Hello, This is a foolish question. It all depends upon the cause of the Cardiogenic Shock. MI? Valve Problem? Infection? Genetic? Auto-Immune? So, I guess I would pick A as well....

Hello Everybody, My apologies for the delay. Here is some much needed information. The chest tubes: The patient was difficult to ventilate. The airway pressures (PIP and plateau) were very high and the patient blew a (L) and (R) pneumothorax. The patient was unstable and this bad turn of events has worsened the situation. A CXR shows complete whiteout of both lungs and two well placed chest tubes. The patient height and weight: As noted by all the volumes are a bit excessive. Lets say according to IBW calculations is 60kg (6cc/kg = 360 7cc/kg = 420 8cc/kg = 480) Do we drop the Vt slowly or quickly? The labs: ABG: 6.9 / 80 / 70 / -11 / 11.2 (ph/co2/o2/be/lac) WBC 25 HgB 60 K 7.0 Na 135 Mg .60 Cr 1200 Ur 50 The vent: AC 20/650/.8/+5 PIP:44 I am not an expert on scalars and loops (I suggest watching chbare YouTube videos) . What I can say is the patient was too awake. Things settle down with proper sedation (RASS-3) and a good suction (copious amounts of secretions) but work still needs to be done. After suctioning and sedation only Vt of 100-125 is being delivered. Thank you, David

Hello, The ET and CT x 2 are in good position. The patient decompensated from the pneumos and the insertion of the chest tubes. The Fentanly is at 100mcg/hr and Versed at 5mg/hr. She moves her arms wealy from time to time. The patient is on AC-VC with a volume of 650cc with a rate of 20. However, the high pressure alarm is ringing madly (PIP 40). ETCO2 is 55. They are considering stopping the ventilator and bagging the patient. You start some IV fluids. You push IV pressor of choice and the BP improves some. NKDA The patient had an admission 18 months ago for an autoimmune vasulitis of her lungs. Despite an extensive workup no soild dx was made. However, she resonded to Methotrexate and was switched to oral steroids. The patient secretly stopped taking the steroids due to excessive weight gains. Also, the patient had flu-like symptoms and has developed a red lesions on her feet. Thank you, David

Hello, You are dispatched for an urgent transfer from a regional hospital ICU to a larger university hospital. You arrive to a very hectic and busy room in the ICU. An 18 year-old female was admitted three days ago for worsening SOB that has progressed to respiratory failure that required intubation by day 2. Things have worsened dramatically over the past 24 hours. She is sedated (Fentanly+Versed) and ventilated. Alarms are endlessly ringing. VS as follows: HR 150 BP 70/40 SpO2 72% Lastly, bilateral chest tubes have been inserted. Thank you, David

Hello, Sorry, I forgot to add this in my last post. It is about 15 minutes to the airport. The flight time is 45 minutes followed by a 15 minute drive to the university hospital. So, out of hospital time will be around an hour. I will more later. Triemal04.....very nice post. Cheers

Hello All, The patient has a history of IHD, HTN and methadone use for chronic pain. He also suffered two previous head injuries (#1 was a MVC #2 was from an assault). Also, the patient has an ETOH history. He takes ASA daily, a round pill to control his mood, and Ativan for his nerves. The hospital did a FAST, CT and a CT-A and they only found the vascular injuries. The CT reports says, "...transection of right superior thyroidal artery with large hematoma that is displacing the larynx leftward....." and "....right innonimate vein transection with large hematoma that extends below the aortic arch...". Initally, in the ED, the patient was stable. He tolerated the CT/CT-A without issue. Unfortunately, he has been getting restless over the last 30 minutes or so. On arrivial, he was hypertensive (140-130/89-90) and tacychardic (100's). Now, his HR is in the 50-60 and his BP 80-90/40-50ish. The right hand was lacerated when the coffee cup he was holding shattered. There is a large laceration on the top of his hand that is oozing blood. The whole right arm is cool to the touch and looks swollen. The BP cuff is on his right arm. On exam, the patient is anxious but following commands. The left side of his head is covered in sweat while the right is dry with ptosis. He says his back, neck and hisp hurt. His voice sounds hoarse and it hurts to swollow. Lungs are clear. Abdomen is soft with a selt belt bruise. Labs are pending and they have cross matching for blood. The patient has been given Ancef 2gm IV, Morphine 2.5mg IV PRN, and NS1000cc. They have not considered TXA. In addition, they are not keen on intubation. They think he should go as is. The neck patient has been accepted at the local university hospital for a trauma team activation (to reassess before the OR). The second patient has not been accepted for transfer yet (....however they would love for you to take both patients!!!!.....the pane can fit two BTW) Cheers

Hello City, You are part of a fix-wing critical transport team. You are diverted from a previous mission for a trauma patient. You receive a brief patient update: A 67 year-old male was involved in a high speed MVC. He has sustained blunt trauma to his neck. He has been assessed by the community hospital’s trauma team and a CT and a CT-A has been done. The scans have noted a transection of the right carotid artery, right superior thyroid artery, and a transection of the right innominate vein. His VS are: HR 50 BP 90/50 Resp 24 SpO2 95% on NRB. You arrive in the ED and your patient is sitting up, in pain, and anxious. Blood soaked gauze is wrapped around the patient right hand. His neck is brusied on both sides and you see bulging on the right side! In the room next door, the driver is yelling profanities, while the staff is splinting his fractured ankles. The ED staff seems quite pleased to see you. Cheers, Dave

Hello, Thank you for posting. Lets start with our initial assessment. GCS? ABC? Get her on the monitor and see what happens next. David

Hello, In Critical Care Nurse there is an interesting article by Darcy Day 'Keeping Patients Safe During Intrahospital Transport'. In this article, MV was cited as one of the more frequent transport complications. http://ccn.aacnjournals.org/content/30/4/18.full.pdf+html?sid=579629ec-4b18-4469-a31f-3757feb3ddb5 I agree with iStater and Triemal04 that caution is the best option with these complex patients. Change things slowly. I have seen some teams (...and I have been guilty of this myself...) of mucking around too much. Cheers Hello iStater, "Transport ventilators do not compensate for compressible volume loss." How do you calculate this? Do you double you PIP? Thank you, David

Hello, This patient has chronic pain. In the initial post, if I recall, there was indication that he has been taking extra Oxy for pain. From my experience it is not uncommon for chronic pain suffers to take an extra dose. Especially when there is some acute on chronic pain. Also, it is difficult for these patients to OD with opiates alone (mixed OD is a different case). In fact, looking back, I have seen more opiate OD in the hospital setting with opiate naive patients. In the prehospital I only have seen one opiate only OD that was serious (of course some geographical areas are different....I had a friend who worked in Philadelphia in the 1990's....I degrees). Second, this fellow had a rapid decrease in LOC. Is it primary a cardiac event or is a neurological event? With a sky high blood pressure, abnormal muscle movements, and deviated gaze I am thinking neurological. As for the bradycardiac. First, take a quick listen to ensure that we have good air entry and make sure we do not have an pneumothorax on the go. I would give him Atropine 1mg IV (so much for pupils checks by neurosurgery.....lol). Give Propofol IV PRN and aim for deep sedation. With luck, this will reduce his assumed ICP. I would also work on bring down the CO2 to 40 or so. Get him loaded with the HOB at 30 degree and head inline to ensure good venous drainage. Cheers

Hello, Thank you for post a scenario. I agree, this fellow needs an airway (protect and predicted course). I would do an airway assessment, set up the equipment and brief everybody on the plan. I am not sure about Vecuronium because I have no experience with it. If I recall it is fairly long acting. I would go with Rocuronium 50mg IV followed by Propofol 100mg IV. My rationale for Propofol is it is neuroprotective and we have plenty of pressure to work with. For post intubation management I would use a Propofol gtts (if you have a pump) or Propofol 50mg IV PRN. My goal ETCO2 would be 40. If possible, I would try and get the BP below 160. As for the ugly EKG this may be due to ICP and brain stem issues. Cheers

Hello, Thank you for posting a scenario. If the ALS unit is only 15 minutes away perhaps staying might be a good idea. It will take time to get this unstable child into the ambulance. Second, this is an anxiety producing event so people will be on edge. I have seen a few BLS/ALS intercepts turn into a gong show because the units fails to RV at the correct location. Unless of course a hospital is very close. Then maybe transporting the patient to an ED could be an option. The BLS crew should give epinephrine IM, get him on a stretcher, monitor, o2, and a line. If they do not have epi they should see if the mother has another epi pen to give. Cheers

Hello, Thank you for the answer iStater. I have seen a few occasions in the past that people rush too fast to the minimal 6cc/kg VT or have made the VT so small that nothing much is left after deadspace. Thanks. I am unsure of all the details. As we all know follow up sometimes isn't the easiest. The patient had developed some sort of fistula from the spinal needle. Hence the massive air leak. Luckly, the leak went away with an occlusive pressure dressing. This lady was sick. The question is, "How much do you try and fix or change before you leave?" Sure, you know that things are a little off the rails but do you or can you fix it all? My point of view is effected by the fact that I have spent a long time in the critical care setting. You slowly make changes over a shift or a few days. Cheers

Hello, Thank you for an interesting scenario Chris. SAH and other catastrophic neurological events can cause a profound dilated cardiomyopathy. A neurosurgical unit I worked at many years ago saw a few 'stunned hearts' from SAH. Also, a year or so ago, a women came into the ED with a SAH (grade III) was hypotension despite and impressive ICP. However, I have never seen or heard of QRS prolongation from a SAH. In addition, it is fairly common to have ST elevations with SAH as well. Why this happens........who knows!!!!......I have never found an adequate answer nor received one the many keen people I have asked. Overall, I can not think of anything to add treatment wise. Fluid and a Levophed or Epi to support the BP. Chris, I am interested to hear what the outcome was. Cheers, David

Hello, I had a great reply and I lost it. =( Ok, iStater, she has been on these setting for around a day. I can not comment too much on the waveforms (not my strongest area). However, I can say they look like normal shark-fin like volume waveforms without any auto-peep. You work out her ideal body weight lung volume and lets say it is 450cc. The red spot is from the needle decompression after she developed a tension pnx from a central line attempt. Now, when you push down on it the air leak stops in the chest tubes. Also, when you push on it the turbulent noise stops. Very odd. Here is a question for you. I know that ARDSnet like small tidal volumes. Now, for the small peanut sized patients is there a point that you just can not cut the VT? Otherwise, the way I see it, the dead space will eat up most of your VT. Rock Shoes: Good idea, you push Tyl 1gm down her NG Thanks...

Hello, I was going by memory, but in essence, the ABG shows ok oxygenation and co2 for such sick lungs. The bad BE and lactate is from poor perfusion and worsening renal function. Her earlier ABG look awful with low PaO2 (50) and hight PaCo2 (70) ON 100%. When you listen to her lungs you hear a loud turbulent sound and feel some subcutaneous air. Incidentally, there is a red spot were she was decompressed with a spinal needle. The chest tubes are bubbling vigorously. The consensus from the post seem to want to reduce sedation to improve hemodynamics. So, you back off on the sedation and for the sake of argument you go with Ketamine or Propfol. You can back off on the Levoped some as well (.3mcg/kg/min). This improves her pressure some. She is in the 100-120/50 range now. HR is still 100+ and her temperature is 39.5C. The nurse says she is doing ok now but if you move her too much she SpO2 bottom out. We are on the fence about the Nimbex it seems. Cheers Hello, She is 80kg and around 5 feet tall. You do an other gas (please don't look too closely at the numbers) and her PaO2 is 60 and her PaCO2 is 45 with a pH of 7.40 or so. The RT flow sheet and the notes are erratic and it is hard to figure out how she arrived at her current setting. Thanks

Hello, Sorry for the slow reply. I upgraded my computer at home and I can not figure out how to turn off the 'ad blockers' software and I can not login to EMT City. I will get my IT department (brother-in-law) to fix things for me. The chest tubes were put in because the patient developed a tension pneumothorax after a couple attempts at a central line. The patient coded and a spinal needle was used to decompress her (that all they could find in a rush) There is a small red spot where the needle was inserted. Her CXR is white out with a small effusion on the right side. The chest tubes are in good position on the left. She is positive 6000cc and her urine output has been falling. K 5.2 Na 145 Hgb 80 Lact 9.0 Cr 200 Urea 12 INR 1.5 PTT 55 She has a right femoral central line and IV x2. She was a right radial arterial line with a good waveform. She is on AC 25/550/1.0/+22 ABG (7.40/60/45/-11/9) with a PIP of 36 She is on Levophed at .5mcg/kg/min (80kg so 40mcg/min) Propofol 150mg/hr + Fentanyl 150mcg/hr + Versed 5mg/hr. Her BIS is 35 so she is deeply sedated. The Nimbex is a 2mcg/kg/min (TOF 0/4). Otherwise, she is a healthy 52 year-old women who is a little overweight who walked in very ill. Cheers

Hello, You are part of a ground critical care transport team and you have been dispatched to transfer an influenza patient from a community hospital ICU to the local university hospital. The transport time to the university hospital is 90 minutes. The patient is a 52 year-old women who present to the ED three days ago with SOB, confusion, hypotension, and respiratory failure. She was intubated, started on antibiotics, given IV fluids, and admitted to the ICU. Her condition has decompensate further and she has been started on Levophed to support her BP. In addition, she has been difficult to ventilate and has had two chest tubes inserted for a left-side pneumothorax. You arrive and you find the patient sedated (Propofol + Versed+ Fentanyl gtts) and paralyzed (Nimbex). Levophed is infusing as well. Two chest tubes are bubbling vigorously on the left side. VS are troubling (HR110 BP 90/40 SpO2 88% Temp 39). Lastly, your patient is looking gray with mottled feet. Cheers David