Aussieaid

Thank you for letting us know. I’m so sad to hear this. He was a kind and funny guy. He would have turned 30 next month, I think. So young and tragic timing. 😢

I don't know how many people remember me or Fireflymedic but since I met her on here a few years ago and it was the beginning of our friendship I wanted to update EMTCity on her sad news. About a week ago her husband found her unconscious up against the bathroom door when he got home from work. She had been struggling with getting her seizures under control. She coded en route to the hospital and has been in the ICU for the past week. The latest news is that her husband will be taking her off life support on Sunday as she had too great of a hypoxic injury and recover. I just wanted the City to know as I am sure she still has City friends around. RIP Fireflymedic. You will be missed. <3

NRB is always a better choice even for an infant if they tolerate it. IF they don't then you use a different option like blow by with a regular NRB. You can often tape the mask below their face or even wrap a teddy bear around it and position it as close as possible to them. I'm not sure what a paper cup is going to do better than a NRB? Seems like a regression in treatment to me. A 4 year old asthmatic is probably used to using masks for home treatments most likely anyway. We put kids and infants on NRB's all the time... they don't all get upset about having a mask on or near their face. They often tolerate it better if a parent is holding it as well.

Zoll X series is based on the Propaq MD which is used extensively in the air medical industry. I like our propaq MD. I understand the Zoll X can also do carboxyhemoglobin and methemoglobin monitoring which would be useful for fire incidents. It also has the CPR feedback. I much prefer the size of the MD Propaq and the zoll X is similar size. They have everything we need for a critical care patient without having to carry both a monitor and a defibrillator so we are very happy with them. They also have the option to wirelessly transmit EGKs to the receiving facility if it is all set up.

Hmmm, nagging like a potential aortic dissection? Nitro good...ASA and heparin not so good.

I'm positive the diagnosis was made AFTER the patient had a CT scan and labs done both of which we don't have the luxury of in the field. The first rule of medicine is "do no harm". You always rule out the diagnosis that is most life-threatening first and then work your way down the list. Yes, he had indicators of sepsis (or perforated bowel) and other possible diagnoses but the AAA diagnosis will kill the fastest especially if mistreated. Since AAA was high on the list of diagnoses with his high risk factors (liver failure), hypotension, distended RIGID abdomen (not sure how you could palpate anything with that kind of abdomen) and description of the pain "ripping him in half and through to his back" then you can't rule it out. You don't want to do anything that could make him bleed out faster. Since he remained A&O x 4 throughout, then not pouring fluids in or starting pressors was appropriate since he is obviously adjusted to low BP's and was still perfusing his brain. I have seen too many incidents of people dropping their BP significantly with narcotics to risk it with that level of hypotension (with Fentanyl as well as Morphine). It's harder to get back a code than to prevent one from happening. I am a huge advocate of pain relief and if you gave fluids with no real success and he remained alert then I would trial small doses of narcotics, however he probably only didn't tank his BP because of the fluid boluses given as well. You had no BP readings along with no peripheral pulses so I would have been even more cautious about giving narcotics. Once you rule out the AAA which couldn't be done until the ER, then it's appropriate to fluid resuscitate and add pressors and get his pain under control. Critical thinking is about keeping in mind all the most likely diagnoses and balancing the treatment so you don't make the patient worse by mistreating one possible diagnosis.

If we are thinking ruptured AAA there is no indication for inotropes. You will actually make them bleed faster if you raise the BP. Ideally they should be given small boluses of fluid (~250 mls or so) to maintain cerebral perfusion if possible. You should not treat BP just to get a "normal" number. They accept SBP's of even 50-70 in a ruptured AAA pre surgery. The higher you raise the BP the faster they bleed out. Inotropes are not called for in any type of exsanguination as they just make the problem worse. You need to give fluids (preferably whole blood) just enough to keep them alive to get to surgery. As much as I am an advocate for pain control, in this situation with his tenuous BP, pain relief is far down the list. The catecholamines circulating at the moment are probably all that is keeping this patient alive. Take them away with narcotics and you have a dead patient. His BP is also way too low to give any narcotics. You also want a good idea of his cerebral perfusion and don't want to confuse things with narcotics. If he is this shocky he won't be feeling as much pain right now in any case.

Sounds most like a leaking AAA. With his liver failure he is at high risk of bleeding so even a small leak can be catastrophic. Only about 50% of cases of ruptured AAA present with the classic triad of severe acute pain, pulsatile mass and hypotension. He is most likely bleeding into his abdomen from somewhere or other possible diagnoses are a perforated bowel or even severe acute pancreatitis. The mass in his RUQ is most likely his enlarged liver. The medication he was on was probably lactulose which scavenges the ammonia from the blood and into the colon in liver failure patients. It is more commonly used for constipation which is why he has chronic diarrhea. Monitor, 2 large bore IV's, NRB with O2, titrate small fluid boluses to maintain normal GCS. Don't pour the fluids in wide open unless he has altered mental status and severe hypotension just in case it is a ruptured AAA. Treat the pain once you have adequate BP. Rapid transport to nearest surgical facility.

CALSTAR in California has started using it prehospital. I haven't heard how it's going yet. http://www.verticalmag.com/news/article/CALSTAR-Air-Ambulance-leads-country-with-new-treatment-for-b#.UW4v8qUkI20

Any chance it's Cauda Equina Syndrome caused by a local infection? Maybe from Staph? Probably not though, with the more systemic symptoms....

*dips toe in water*.....

RN. Global Slave....

Well, if I was in Oz, I would expect him to bring me goodies from the US.......like....ummmm...ummm.......ok, never mind, I'll just eat my Tim Tams and Vegemite!

When someone's really cold the blood is shunted away from the peripheries (shut down) and to the core organs....when you start warming them up and they start vasodilating then the cold blood starts getting circulated to the core organs and their body temperature can actually drop more. Or that is my simplified understanding of the phenomenom! Correct me if I have it wrong...

Active rewarming can cause arrhythmias and metabolic derangements as well as the risk of afterdrop and rewarming hypovolemia.

Sorry, you are missing out on the truly classic Aussie experience.... No Queensland and no Aussie Aid to show you around! Better bring me some Tim Tams and more Vegemite though, Mate. (Remember Double Chocolate and Turkish Delight Tim Tams, please!)

An incorrectly placed ET is only a problem if it is not recognized immediately which it sounds like it was. Kudos to the crew for going to a supraglottic device after the failed attempt and not wasting time messing further with the airway.

Infusing bags of Sterile water for injection can absolutely cause serious harm!! Infusing sterile water causes hemolysis and can lead to Acute Renal Failure. (Water will enter red blood cells across a diffusion gradient and cause the cells to swell and burst). If you infuse too much too rapidly you can also cause hyponatremia which can cause seizures, coma and death (think water intoxication). The bags of sterile water for injection are for pharmacy purposes only to dilute some drugs (and is given in small quantities and not infused rapidly). If they want to treat hypernatremia in the hospitals they use hypotonic solutions such as water mixed with 4 or 5% dextrose or hypotonic saline (e.g. 0.45% saline) solutions. Any solutions that are going to be infused directly into a patient's vein need to be treated like any drug and double checked. That is why IV fluids are "ordered" by physicians whether it is in a hospital or by standing orders or policies under a medical director. Edited for additional: Osmolality of sterile water for injection - 0 mOsmol/L compared to Normal Saline (0.9%) - 308 mOsmol/L or Dextrose 5% - 253 mOsmol/L. Human plasma is 285-310 mOsmol/L.

I tried to edit it and attach the photo and it showed the download attachment but I guess it didn't work. How do I get a picture in the body of the post? I don't think I have ever tried to post one before.

So if they state they are suffering from eupnea that would make them a classic hypochondriac! Here's a challenge for those of you interested. More of a term of the day but you have to work for it. Look at the x-ray below and see if you can identify the major radiologic abnormality and what is the most common cause of the same.

There is the probability that there was some anxiety involved that could contribute to a higher RR and would be understandable but sepsis, fever and anemia are all have higher oxygen requirements. They fever and sepsis causing acidosis is going to increase the CO2 which she would be attempting to blow off with increased RR. The anemia means that even though she may be saturating almost 100% of the red blood cells there are not enough of them to carry the body's increased oxygen requirements with the sepsis and therefore she has to breathe faster to get more oxygen to the tissues. Short and sweet!

I wouldn't consider it a LODD simply because they weren't on duty.

I would have to say that Nigeria definitely would be a "funny Middle Eastern Country" as it isn't even in the Middle East! Intubating for deep suctioning is not the reason for intubation in this lady. Yes it will help with better suctioning than a supraglottic airway but you are not going to be passing a suction catheter beyond the carina (or end of the ETT for that matter), or going anywhere near the bronchials and the fluid is already deep in the lungs at this point. Intubation in aspiration pneumonia is to protect the lungs from further damage/aspiration and to manage oxygenation and ventilation as they are often seriously injured with the aspiration, rather than to facilitate suctioning. That is more of an extra benefit.

My treatment plans: Mother- Severe DKA with aspiration and coma possibly caused by the DKA or complication of cerebral edema (which is more rare in adults with DKA)- RSI intubation to secure her airway if in protocols. With the evidence of vomiting I would prefer not to put a supraglottic airway in and risk her waking up and gagging and vomiting further. OGT straight after intubation. 2 IVs with at least 2 liters going in fast bolus, cardiac monitor, ETCO2 get her to the hospital - adult. (If the children's hospital is a free standing one then they will not take an adult when the adult hospital is 5 mins away. The children's hospital where I worked at would have freaked if you brought this patient into them. If they are connected to an adult hospital then they wouldn't have said the nearest adult one is 5 mins away.) Baby: Severely dehydrated and acidotic - critical condition. Needs 2 IV's (or go straight to an IO since you will be lucky to find a vein on him and he needs immediate aggressive fluid resuscitation) with immediate fast 20ml/kg NS bolus and repeat with probably at least 2 more fast ones until stable. I am very concerned about his HR but his age would be helpful in guiding how bad it is. If he is a neonate than a HR of 150 with that severity of dehydration...lethargic, flaccid, skin tenting is a poor sign as i would say he is starting to brady down. If it is an older baby then it is still lower than I would expect it to be with the degree of dehydration he is showing. You would NEVER attempt to feed this baby orally in his condition. He is critical right now. His glucose is most likely low and will need 2-4 ml/kg of Dextrose 10-12.5% if under 4 weeks or Dextrose 25% if older than that. Repeat as required to stabilize his glucose. I would even consider intubating this baby as well. He is in very poor state. If he doesn't start to improve after a couple of fast fluid boluses I would be intubating him. He also needs to be covered with blankets and warmed up as well immediately. He needs to go to a dedicated children's hospital especially if it is closer. More vital signs on this baby would be a good thing and he needs cardiac monitor as well as temperature control (place a wrapped warming pad under him if you have one).

There is a Mnemomic for situations just like this (trouble shooting deteriorating ventilated patients): DOPE D- Disconnection (Can add displacement) The circuit is disconnected somewhere either at the tube or somewhere along the ventilator circuit. In the case of displacement the ETT/Trach has displaced and the patient has extubated accidently (or self extubated). O- Obstruction Either the ETT/Trach is plugged with a mucous plug (or cockroach, etc) or the tube or circuit is kinked somewhere. P-Pneumothorax Pt has blown a lung or two causing a pneumothorax which can quickly progress to a tension pneumothorax. E- Equipment The equipment has failed. Either something is wrong with the tube (leaking cuff), the ventilator or the ambubag (not connected to oxygen for example) Your first action with a ventilated patient should always be to disconnect them from the ventilator and bag them. By the simple act of doing this it will narrow down the possible causes faster than anything else. If you start bagging and the immediately improve then you know the problem is with the equipment. You stabilize the patient and then you can trouble shoot the equipment. If you start bagging and they are hard to bag you can narrow it down to an obstruction or pneumothorax and know that the problem is with the patient not the ventilator. If you start bagging the patient and they are easy enough to bag but don't improve then you check your oxygen source, tube placement and cuff pressure. If you are in doubt that the tube is in the correct place then you immediately pull the tube and revert to BLS airway until the patient is improved or stable enough to reintubate. One of the most valuable tools that you can use is some form of capnometry. If you can't afford a proper piece of equipment with a waveform that can tell you so much more than you can imagine, then you can use a simple ETCO2 detector that just changes color. If you have confirmation that the tube is in place quickly then you can save pulling the tube and focus on an alternative cause of the deterioration. I have to say that I would run as far from that program as I could if they think it is ok to send an obviously untrained (in CCT for sure), single paramedic provider to transfer a septic, intubated, ventilated patient on pressors.