DartmouthDave

Hello, I have had limited experience with burn patients and only one of these was during the acute phase. He was transfer to a burn center at a large teaching hospital and they didn't want prophylactic abx given. Second, I think the cost would be an issue. Most of the abx carried would expire before being used since (lucky) critical burns are not that common. Cheers....

Hello, Best of luck. I loved Jasper. In fact, I started in EMS in Lake Louise, Alberta a long......long time ago. Cheers

Hello, Jasper, Alberta? If so, Associated Ambulance operates there. Well, at least when I was there a year ago. Cheers

Hello, Thanks for posting Tripp. I think PM summed it up quite well: "Generally, if the patient is just fat you shouldn't get pitting like you would with edema. If there's a fluid shift like you see in edema you should see some form of indentation that takes a few seconds to resolve. Combine that with the rest of your physical exam findings and it should give you a better idea if it's just fat or something else." Medical history and medications can help fine tune things. Onset of symptoms: fast or slow? History of hospitalization? You get my drift. Sure, it could be COPDE or CHF or something totally different. PE? ARF? Way back in the day I did a call for a 125kg (or so) 28 year-old male with a c/o SOB and SOBOE. No past medical history or medications other than NSAID and Tly for MSK pain. Smoker. Worked as a bouncer in a dive of a bar and lived in a hotel room. Wheezing lungs. Pedal edema. I figure he was developing failure. It turned out he had Nephrotic or Nephritic Syndrome (can't recall which one) and he was medevac to a larger hospital later that day. So, I think management with Salbutamol, positioning, o2 and transport is a good idea. IMHO. Just one quick general questions here. I assume most areas treatment of CHF is NTG SL? As opposed to Lasix and Morphine? Thank you DD

Hello, O2, IV and transport. No ASA or NTG. Could be a STEMI only. Could be a STEMI with a tramatic injury. Could be a STEMI with an occult injury. Could be a cardiac contusion. So, IMHO, a work up by a trauma team at a hospital with angio. What if this patient needs a laparotomy? With a short transport time in my mind the risk/benefit isn't there for more agressive ACS management. Thnak you PS.... Hmmm...since the only scenarios as of late have been posted by me it is hard not to feel a finger drifting in my direction. Just saying.

Hello, I have always heard it pronounced with a 'G' not a 'J'. Was the Neurologist British and wearing an ascot? =) Cheers

Hello, Myasthenia gravis is an autoimmune mediated attack on the Ach motor receptor. Manifests as weakness and fatigue. My knowledge of this condition is quite weak. I know that Sux is an issues with these patients. As well as any anti-Ach agents such as Neostigmine and Glycopyrrolate(I think(. I am not sure if this patient has Myasthenia Gravis. It is my understanding that it is a motor disorders only. I will need to check this. Gillian Barre Syndrome (GBS) is an autoimmune disorder as well. Typically triggered by a prodromal (...nice big word drop eh?...)viral or bacterial infection. It causes demylenation on the motor and sensory neurons. Loss of the myelin sheaths causes conduction on action potentials to slow at first the stop. Therefore, the longest motor and sensory axons are effected first. The longest ones inervate the legs. This is why weakness and numbness start there and marches upwards more myelin is lost. Pardon any typos. I am knocking this off at work when I should be working.... =) Cheers

Hello, GBS!! Weird how the face and hands were effected before the feet. =)

Hello, With the numb feet GBS comes to mind. But, from my expereince, for what it is worth, GBS starts distally and marches upwards. I am stumped. BTW, Tniuqs, what do you care about hair colour? I am afraid to ask. LOL. Cheers

Hello, Nice post Bieber. As you know, geriatric patients present differently. Perception of pain may be effected by DM as well as other health issues. Bones are more brittle. In general, a decline in muscle mass also afford a lesser degree of protection from trauma. I would be leery of using an ACS protocol because of: 1) Significant MOI 2) Patient's age 3) No history of chest pain prior to smash up 4) Skin is warm and dry 5) VS stable Some DDX could be: 1) Rib fracture(s) 2) Pulmonary Contusion 3) MSK pain I would also like more of a medical history and medications the patient is on. However, any actual dx in this setting would be difficult. So, transport to a trauma centre for a FAST/XRAY and a trauma work up would be the best option. IMHO. Cheers

Hello Dig Doug Guy, If Critical Care Transport is what you want there are two routes. Become an RN work in a high acuity ICU and collect various certifications. Then apply to a medevac service. Or, take your ACP (EMT-P) and work towards the same goal. From the sounds of it you want out of the hospital setting. Go for option #2. Also, seen if you can get a CNA position in an ICU. That way you get to see critical care first hand. Best of luck.... Besides, your only 27....you have time to sort stuff out!!! =) Cheers

Hello, LOL. Ones attitude towards the age of consent changes when you have children. As opposed to back in the day. =) Cheers

Hello, Wow. I am at a loss here. I assume she was null-para. The cervex should be closed and I can not see how the placenta and fetus could prolapse. I will add my guess and go with Uterus Prolapse. Time to dust off a OB text. Cheers

Hello, I moved to a new city and there is the funniest street name I have ever seen -----> BUDDY DAVE DRIVE Anybody have any other unique names to share. Cheers

Hello, An excellent and honest post CM. I read that article in JEMS and I have been there as well. For me, the key has been taking adequate vacations and avoiding falling too deeply in to the OT trap. Avoiding 'toxic' colleagues and taking on new educations challenges and new jobs as well. Cheers

Hello, "A/C is a better choice to reduce WOB, however requires closer monitoring, which shouldn't be an issue as your at bedside 100% of the time." Good post. You are correct about the potential of mechanical ventilation increasing the work of breathing (WOB). In general, a ventilator is able to deliver three types of breaths. With A/C delivering the first two: Controlled & Assisted. Controlled - the ventilator triggers the respiratory cycle and end it at a preset volume or pressure with the WOB removed by the ventilator. Assisted - the patient triggers the vent and the ventilator 'assists' or finished the respiratory cycles with minimal WOB for the patinet. Spontaneous - the patient starts and strops the respiratory cycle with the WOB depending upon the amount of pressure support provided. Also, like usalsfyre noted, pain control is key. In some patients with pulmonary contusions and fractured ribs adequate pain control or blocks (epidurals, paravertebral, ects) are all that is needed to prevent respiratory failure and possible intubation as well. Cheers

Hello, Sorry for the slow response. It seems I always get slammed at work when I try a case study. Excellent post. It is not what you can do but 'understanding' what is going on and what needs to be done the most important. You are bang on with: (1) Preventing hypothermia which is a killer in trauma patients (2) Reducing the fracture is good as well for pain control...like you said...also, to control bleeding which can be substantial and poorly tolerated by a older hypothermic patient (3) Recognizing the need for U/S, XRay and the OR......key concepts found in ATLS/BTLA....nice Here is a question for you: What do you think is causing the ugly looking EKG? Cheers

Hello Paramagic, Looking back, I may have been over the top, but I was trying to demostrate a decreasing pulse pressure due to hypovolemic shock (stage II leaning towards stage III). Here is a site that I think is interesting: http://www.stagesofshock.com/ Also, good point on the blood as well. This patient is a 'non-responder' to fluids. A unit of blood arrives from the blood bank started to infuse via a pressure infuser. The RT is preparing the intubation equipment and the RN is preparing the intubation medications (Etomidate/Sux)while the Dr preforms an airway assessment. Cheers

Hello, The local trauma centre has been contacted and medevac is currently being arranged. Here is a summary of the treatment suggested so far by various posters: 1. CXR 2. FAST (The Focused Assessment with Sonography for Trauma...aka...F.A.S.T) 3. Reduce the midshaft femur fracture 4. Provide pain control 5. Give fluids/blood 6. Stabalize the pelvis 7. Warm the patient The results of these interventions are as follows: 1. CXR shows no pneumothorax. However, multiple rib fractures on the left and right side. There are also pulmonary contusions as well. 2. FAST shows a reptured bladder and some free air in the abd as well. A grade I splenic laceration (not too bad) and a liver lacerations as well. The heart looks fine: no contusion or effusion. 3. Traction is applied to the fractured femur and pulses return to the foot 4. The patient is given some Fentanyl IV but dose not help much. 5. The patient is give 1L of warmed NS 6. The pelvis is stabalized with a pelvic binder 7. The temp is now 36 and the patient has stopped shivering Despite this VS decline somewhat: GCS 14/15 Confused BP 100/80 HR 130-140 AF with PVC++ Resp 30+ SpO2 90-91% on NRB Cheers Have to run

Hello, Excellent work. The patient is exposed. A seat belt sign is noted across his chest and abd. Blood is also noted at urinary meatus as well so a hold on the foley for now. Also, increased work of breathing is noted. Resp of 30+ and shallow. 'It hurts too much to breathe!!!' The abd is tender to the touch. The right leg is shortened and rotated. The foot is cool to the touch and has no pulse. A bear huger is applied to the patient. There is no CT scanner at this hospital. There is xray and u/s. I will post more latter. I need a nap before night shift. Cheers

Hello, You are transferring care of a stable patient at the local ED when you hear that a trauma patient is being transfered in with a BLS crew. You and your partner are asked to stay and assist the local ED staff. The hospital has basic laboratory capacity, x-ray, u/s and a small blood bank. On duty are 2 ER Nurse, 1 ER DR and a RT. The BLS crew arrives and gives a report on their patient. A 70 year-old male was driving his SUV when he fell asleep at the wheel and drove into a cement divider at highway speed. Their was extensive damage to the vehicle and the air bags deployed. Lucky, the patient was wearing a seat belt at the time. The patient was not entrapped and was extricated quickly by Fire and EMS. The patient was secured on a back board and a c-collar applied. He has one #18G IV in his left ACF and has a NRB@15 lpm. His VS are as follows: GCS 15/15 BP 110/80 HR 120-130 EKG A.Fib with frequent PVC's Temp 35.8 Resp 32-34 Rapid/Shallow Spo2 94-95% BGL 18 mmol/l The patient is moaning in pain and shivering. He complains of sharp pains on the left and right side of his chest and pain in his right leg. Also, the patient c/o suprapubic pain. He keeps trying to sit up because it is hard to breathe on his back with all of this pain. The right leg is shortened are rotated externally. The patient is fully clothed and wet. It is a cool wet spring day. The BLS crew states that the patient has a history of CAD, AF, HTN, Dyslipidemia, DM II and depression and ETOH abuse. The depression and drinking has been going on for three months since his wife died. Before this, he seldom drank. He can not recall all of his medications. He takes ASA and a green pill to 'thin things out' for his irregular heart beat. His Dr started him on an antidepressant but he never started to take it. He figured he would come around on his own. Cheers

Hello, No central line in situ. Phenylephrine dose not cause damage as much tissue necrosis if infiltration of the IV occurs (according to our IV therapy manual). Also, it can be given IV push PRN (100-400 mcg IV as needed) as opposed to an infusion. Running an infusion could be an issue if blood is going, Panto, ect. We usually put 10mg in 100cc minibag of NS for a concentration of 100mcg/cc. You are 100% correct about the catecholamine stores. But, their depleation effects all pressors. I don't think Neo is more prone to issues. I will have to look this up. Thank you

Hello, HR 126 with modest BP. So, give some more fluid once the blood is done. Make the Panto an infusion, if possible, as well. Also, his INR is still elevated (3.2). Some, FFP if possible could be helpful here as well. Now, I am sure that this wouldn't be availabe in this situation: Octaplex (Prothrobin Complex Concentration <PCP>) can be used to fix his INR as well. Also, prepare a little sedation if needed if the patient perks up some more. What is his temp? If possible, I would like warmed fluids. I just don't want him to get too cold. Hypothermia is a sure fire way to worsen shock and coagulation issues as well. My new soap box if you will. I think, I would get Phenylephine ready just in case he needs it after properly resuscitated with fluids. As for the DNR. I think we need to keep in mind that we don't know the etiology of his lower GI bleed. Could be malignancy. Or, a reptued diverticulum. So, take some time to maximize the odds of a sucessful transfer. I have seen some train wrecks live to leave the ICU. Cheers

Hello, Question 1: Most sources I read stated that Atropine will be of little use because the bradycardia is not parasympathic in nature. But, can be given anyway. Question 2: I threw this question out there because I read in Goldfrank Toxicology (I think...sorry my reference material is not handy) stated that Atropine may prevent worsening of bradycardia due to vagal stimulation during intubation. Of course, I have never seen this done or heard of such a thing. I was wondering if other poster may have. Also, this concept flys in the face of question 1. Question 3: Good job Artikat! Question 4: Yes and no. With the IR tabs CaCl helps mitiagte the toxicity. In cases with SR tabs one can run in to issues of Ca toxicity and diminishing returns. In that Ca influx is blocked at a cellular level. Now, of course, this isn't a typical EMS problem of course. Still, interesting! With these patients whole bowel irrigation is helpful as well as other unique therapies (high dose insulin and glucose and a few other) Cheers

Hello, Sorry for the slow replay. Very busy this past week. So, the standard therapy of CaCl and Glucagon improves the patient slightly. BP is 90's HR 60's and LOC perks up some (GCS 10/15 - E3 V2 M5) Resp are 10-12 with a SpO2 92%. So, here are a few points to ponder: (1) Is there a role for Atropine with a Beta Blocker and CCB overdose? (2) If you were to intubate this patient would there be a role for pre-medication with Atropine? (3) Why is Glucagon useful in treating a Beta Blocker OD (and some sources state effective with CCB as well)? (4) Is CaCl an antidote for a CCB overdose? Cheers.... This is based on a very interesting and complex OD that came through the last ICU I worked at a year or so ago.