Aussieaid

That has to be one of the most confusing statements regarding congenital heart defects and oxygen I have ever read! Generally when people talk about oxygen being harmful in CHD it is with ductal dependent lesions where you actually need the ductus to remain patent as it is life-saving. In these cases in an infant, if you give oxygen it can cause the ductus to close and that may be the only way that the body is getting ANY blood flow or oxygenation. Increased oxygen levels contributes to closure of the PDA not causing it to remain patent. If you want to close when it shouldn't be open, they are treated with Indomethacin or surgery. You're partially right in that it can also cause undesirable shunting and in in some cases cause the lungs to be flooded which can be detrimental in some lesions. Oxygen can decrease pulmonary vascular resistance which can cause more of a left to right shunt and flood the lungs with too much blood flow in some cases. It's not a matter of bringing oxygenated blood where it's not supposed to be but more a matter of too much blood flow that interferes with oxygenation of the blood in the lungs. However very few people are going to have enough of an understanding of all the potential cardiac defects and hemodynamics to differentiate which defect oxygen is going to be detrimental to. Since they are the minority rather than the majority of cases it would be more harmful to withhold oxygen than to give it and titrate it to effect. IF the patient condition does not improve or deteriorates with oxygen then it should be removed. That is in regards to CHD in any case.

Largest medevac scene I was involved in was a bus crash with ~28 patients, 14 criticals. There were 7 helicopters that landed at the scene (not all at the same time- I think there was 3-4 landed at one point). We flew one critical from the scene and another from a local hospital. Our company alone flew 14 of the patients either from scene or local hospitals to trauma centers and there were about 2 other helicopter companies involved as well. I can't imagine being on the ground for that kind of scene but I can say that they handled it fantastically. There was good communication among both ground and flight crews. The whole county did a great job with their response. I've actually been to a number of 2-3 aircraft scenes with all the aircraft on the ground at the same time at some points.

AK, I thought we did the mythbuster routine on that phrase and .....nope.....still doesn't cut it! Have fun in Oz, Dwayne!

Look up epidural hematoma and lucid interval. That's just one of the reasons it's important to know if they had a loss of consciousness or not. Just because it's seems like everyone is saying they had one it doesn't diminish the fact that it is important to know if they did have one, like the boy who cried wolf. If you are suspicious, then by all means ask more pertinent questions like Dwayne suggested. He is still looking for the same pertinent piece of information.....did they have an LOC or not. Half the time my patient's wouldn't remember but I used the same method of asking what they could recall of the actual event which still doesn't tell you if they definitely had an LOC but can more likely rule out if they didn't. If there is even a brief LOC it is important to know, not only for the potential epidural (think Natasha Richardson) but also because it is relevant in classifying the degree of head injury. Studies have shown that multiple mild concussions can be just as bad as a single more severe head injury. If the force was severe enough for them to lose consciousness even for a short period then the brain has sustained a significant impact that warrants further investigation or at least monitoring for longer than a non LOC event.

I have to say that whoever made that statement is pretty ignorant about the role of contractors in recent wars. The way the military has been spread out and the length of the conflicts has made contractors vital to any war efforts. Who do people think run the DFAC's for the troops, interpret for the military, truck supplies in, lay the communications cables, builds a lot of the infrastructure, run a lot of things on bases including the ATC towers and the base EMS just to name a few of the things they do besides private security.

I would say nobody has the right to make you file charges if you don't wish to. It's a legal matter and not just as simple as filing a report. If the Doctors truly believe that he is a threat to himself they can hold him without the police having to file harassment charges against him. They would put him on a psych hold. Don't be emotionally manipulated into doing something you don't wish to do, especially when there can be significant ramifications from those actions. The Deputy may think they are acting in the patient's best interests but this is not the appropriate way to go about it and she had no right to ask such a thing of you. Just my 2c worth!

Thanks Dwayne! Keep the tips coming..... I might have a problem with obtaining the Penthouse magazines as things are a little stricter these days I gather. I am, however going to be investing in a supply of Tim Tam's and they work wonders!! Kept him in line last time I had a supply....been too long since I had any I guess. (Or maybe that was my last boss.....things are beginning to blur...)

First can you tell us whether by the child having had the Norwood procedure, do you mean the BT shunt or the Bi-directional Glenn, which by age 6 months this child should have had? This will make some difference in the treatment of the child. After a HLHS baby has had the first operation, the BT shunt, giving oxygen no longer becomes a problem. The only blood flow to the lungs after the BT shunt (Stage I) surgery is through the shunt and you are not at risk of flooding the lungs with the size of those conduits unless for some reason they put in too large of one. If that was the case they would not have left the hospital, as it would have caused problems immediately. They usually close the PDA with this surgery as well so the body is not dependent on it. When the child is first born with HLHS the only outflow from the heart is through the one outlet (usually) which is the Pulmonary Artery. The only significant blood flow to the body is through the PDA. Normally the lungs have a lower resistance level (PVR) than the systemic perfusion (SVR) so if you reduce the resistance in the lungs with oxygen (causes vasodilation in the lungs) you will increase the blood flow to the lungs, thereby "flooding" them and shunt the blood away from the higher pressure of the systemic circulation and the body. With the first stage of the Norwood procedure they place a conduit from either the subclavian artery or more commonly now, directly from the single functional ventricle (RV in this case) and connect it to the Pulmonary artery. This supplies the blood flow to the lungs. The aorta and the pulmonary artery are joined together to create a neo-aorta that pumps the majority of the blood directly to the body. As was stated, you will never achieve 100% because you are mixing arterial and venous blood in the systemic circulation. If they are lower than their "normal" oxygen saturations then they do need oxygen and there is more concern for withholding it than giving it. The three main causes for lower saturations along with the tachycardia in this baby are possible stenosis or blockage of the conduit, sepsis or CHF. CHF in this baby is not going to cause the usual wet lungs because if the heart is not pumping hard enough it is not going to be getting enough forward flow to get blood to the rest of the body let alone to the lungs. Cardiac babies/children can turn septic in the blink of an eye from the tiniest thing and they deteriorate fast. They don't always have a fever either although the lack of one would make me think more of a cardiac problem first. Why I asked what stage Norwood they are, is because if they have had the Glenn Procedure they could also develop Superior Vena Cava syndrome in which case sitting them upright and giving them oxygen are exactly what you would need to do. This facilitates the flow of blood into the lungs with the help of gravity and by reducing the pulmonary vascular resistance. Treatment plan for this baby: 1. Oxygen to get their sats at least to their normal level. I would be putting on a mask or at least providing blow by as best you can. 2. IV. If they start to decompensate on you because they are septic or completely block off their shunt you need access already in place. 3. HOB elevated and keep patient as calm as possible. 4. I would be tempted to head towards the Pediatric facility and the specialized care but be ready to divert at any signs of further deterioration. A lot of adult hospitals are simply clueless with how to treat congenital defects and can sometimes do more harm then good. However I would not blame anyone for heading straight to the closest facility. Rough guidelines for SpO2 goals with HLHS are: Before Norwood stage I: 70's % (preferably mid 70's) (Room air to hypoxic ventilation ~ 17% FiO2 is used generally). After Norwood: mid 70's-mid 80's After Glenn Procedure: mid 80's to low 90's After Fontan Procedure: Normal (>95%)

It's possible she just has DIC but the majority of times that you see DIC it's usually secondary to sepsis or major trauma. It does happen as a primary condition and more likely with a OB/Gyn emergency, just not as common so the assumption is that it is secondary to sepsis. Her history does not rule out or in, sepsis. At this point you are going to treat the patient the same way and she will most likely end up on antibiotics anyway if she survives that far. You are correct in saying that the "tank" needs to be filled and aggressive fluid resuscitation is the priority but you are most likely going to need inotropes as well. Often it happens at the same time because she is going to be bleeding out as fast as you pour fluids into her and you need the inotropic support to attempt to maintain some perfusion to the vital organs until you can control the bleeding. As much fluid as she is going to require including lots of blood products you often need to start the inotropes so you can cut back on the fluids eventually. Otherwise everything is going to pretty much be third spaced and not stay where it needs to be for hemodynamic support anyway. Except for securing her airway, pouring the fluids into her, starting the inotropes and stepping harder on the gas pedal I don't know what more you might carry in the ambulance that is going to help here (unless you carry blood products, Vit K or anything else useful like that). Drive faster, partner!! The PVC's, I feel are a sign of a dying heart so I would not be treating them specifically. Croaker, the risks of using Etomidate versus benzos is still lower I would think in this instance. The amount of benzos you need to give to achieve the same ideal intubating conditions would most likely tip this patient over the edge and you would have a hard time getting her back. The risk of using etomidate is not as high as previously thought either. Ketamine would be the ideal choice here. http://chestjournal.chestpubs.org/content/early/2010/07/21/chest.10-0790 (Sorry, I couldn't get the link function to work properly).

Sorry, I missed the responses here. Mike, I still fly but only when I can't get someone else to do it for me these days. And they are long, international flights instead of short, fun, rotor wing flights. Squint, I think the Boss would like me to go across the hall and yell at him....he doesn't like it when I ignore him but that might be hearsay too!

I should get some photos of the "Chuck" walls to post that the military have up!

Good call, Croaker. I concur with everything you said. DIC possibly from an incomplete abortion or even just the miscarriage ietself with full on septic shock. Absence of fever does not rule out septicemia. If you have an abnormally low white count which happens rather than a high one you don't necessarily get the fever you expect to see. Aggressive fluid resuscitation (meaning more than 2 liters as fast as possible on a pressure bag) with inotropic support is your only chance of saving her. I can see her getting liters of fluid along with blood products in a very short period of time. The onset was not so rapid as it has been coming for days. She is just at the complete decompensation stage and has nothing left to compensate with. If her rash is that advanced she may already be too late to save. She needs antibiotics and blood products fast along with some clotting factors. Definitely ALS intercept if there is any length of time to the hospital. Not only for securing the airway but because you are going to need a couple of sets of hands to push fluids, start inotropes, etc. Might want to check a glucose level as well on the way but not the highest priority. Sorry, I'm just rambling a bit because my brain is in all sorts of time zones right now! She needs her airway secured to take control of her breathing as well. If you only have Etomidate I would still use it as you can give a shot of steroids later but Ketamine might be better if available as it can give you a slight boost in hemodynamics as well. Of course if she is completely out you hopefully won't need anything to assist with intubation. If she has no gag just tube... You can't afford to give her any kind of medication that will affect her hemodynamics as she is already crashing and anything that takes away further from that catecholamine drive is only going to put her into full arrest faster.

That's interesting because it interrupted the programming in Dubai to broadcast the official speech live. Then again it was on CNN in a Middle Eastern Country!

It's interesting how when you mispronounce a word it's a mispronunciation! And before AK gets a word in...having an accent is not the same as mispronouncing a word! (Americans have to change everything- pronunciation and spelling!) Here's one to put in your report for your next TBI patient (that patient that keeps repeating the same thing over and over again!): per·sev·er·ate    [per-sev-uh-reyt] verb (used without object), -at·ed, -at·ing. to repeat something insistently or redundantly: to perseverate inreminding children of their responsibilities. I actually used horripilation in a report once to see who was paying attention! It's such a funny word.

Below are a couple of studies that showed there was no instability with either D5W or NS. No degradation even started until at least 18 days which is not even a consideration. http://www.ncbi.nlm.nih.gov/pubmed/3706337 http://www.ijpc.com/abstracts/abstract.cfm?ABS=1285 I think you the manufacturer's recommendations are just ultra conservative. In the end it will come down to company protocols but you can safely use either admixture.

My understanding is that you can dilute it with either D5W or Normal Saline for pushes but it is more stable in D5W for longer infusions either intermittent or continuous.

Do you mind explaining the rational regarding your statement, "A low SPO2 reading is one of my indicators to absolutely put the patient on end tidal canula. If corresponding ETCO2 is low, then it is a strong impetus to give em some Os. Conversly, high ETCO2 with low SPO2 becomes a balancing act."?

How about some more history from before the hospitalization. Any exposure to any kind of poisons, insecticides, nitrites, etc? Did they get a methemoglobin level? Is the cyanosis still present with the SpO2 level of 96%? (Might want to increase that O2 flow level anyway).

There are a few brands around and the one that probably "burned" the internal organs (It's not intended to put directly onto internal organs!) may have been Quik clot which used to contain Zeolite beads that caused an exothermic reaction but now they contain Kaolin instead which doesn't burn. There is also Celox and a few other hemostatic agents about. You can get them in powder, granules or impregnated gauze forms. We used to use another version called Surgicel in the hospital when we had wounds that wouldn't stop bleeding or an anticoagulated patient. That worked really well and can be used for internal bleeding too. The failures with the products usually were caused by incorrect application. Once it is applied you need to maintain pressure for 5 minutes or so and then not disturb the clot that has formed. However I think when you have something as severe as a traumatic amputation the tourniquet is probably more effective. I have used it in a traumatic amputation but it is hard to maintain consistent pressure on a large area when transporting. It is good for severe lacerations or heavily bleeding wounds though (especially scalp wounds) and I have had success with it a number of times in the civilian setting. The latest success I had with a hemostatic agent was for a severe epistaxis that had lasted a couple of days and multiple treatments had been unsuccessful in stopping the bleeding. We used Combat gauze to pack the nose. That was what eventually stopped the bleeding and he didn't require evacuation out of theater after all. This patient had been on high dose ASA for 18 years.

I'm an Aussie and I "aid" people! I used to fly in helicopters. I like to be anonymous because I already put my foot in my mouth too much in the "real world". I need to retain some of the anonymity to hide behind! Besides I may need to vent about my job and my boss some day......oh hang on...I better change my screen name first since it was joining EMT City that led to my downfall.....I mean current job!

AK, you're such a stirrer!!! Don't you have enough chaos in your life? Not going to be drawn into a long debate as my time is in short supply right now......but...... Here's a thought: Everything in the universe has it's opposite, hot/cold, winter/summer, girl/boy, etc. The opposite of God is Satan- so we don't praise Satan for all the good things that happen so why would we blame God for all the bad things that happen? Carry on....Inshallah! P.s. You can thank God for me!

http://www.dealmed.com/Products/Backboards/Ferno-Medikids-Pediatric-Board For infants 1-7kg. Has an inflatable section that adjusts for airway management and proper alignment. Snuggle a blanket around them and you can elevate the head of the bed with the board attached (Should be able to on most cots) for respiratory distress babies. Full access and baby is secured.

and works....and works....and works........

I'm paging AK, too! Are you in Afghanistan yet?????? Oh and look...they have my Skype emoticon....

To me this implies that she has obviously had extensive discussions about her wishes with her family. Perhaps they were just not aware that you needed further instructions related to what advanced life support options you do or don't want such as intubation. I would concur with not intubating. I understand the nurses concerns for potential malice on the part of the husband (less likely that both husband and her father would be in collusion) but it doesn't really compare to the rights of the patient to not suffer unnecessarily or have her family suffer with her potentially in a vegetative state. Unfortunately even though she could potentially live many more years without disabling symptoms the fact that she is currently not waking up shows a poor prognosis. The defibrillation part should be covered in the DNR so I would not go there at all. Interested to hear the outcome (and more on the pathophysiology of her presentation!)