Aussieaid

Ok, I guess I and a number of other people who I know have both seen and done this procedure must have been sharing too much of something good (and potent)! Just from a quick search of "Google-pedia": # Now I can understand people being uncomfortable doing this and that is not a bad thing. Not having done that much of a study on it there seems to be some different opinions even on the best time to do it (end inspiratory or end expiratory). I think there is more risk of breath stacking with end inspiratory but I was taught to do it at end inspiratory so that is the method I use. The conundrum of not clamping in a critically ill patient is that that is the only patient that I would even consider doing it on. I rarely do it outside of the hospital setting but when I do it is on the pt who doesn't tolerate that loss of PEEP and lung de-recruitment. That is the rationale: to prevent loss of PEEP and lung de-recruitment. There are definitely times I would like to have a pocket Dr as well as a pocket mechanic however that is just not possible. Ultimately if you are not comfortable with or have never heard or seen a procedure done before than absolutely don't do it. However if you don't open up your mind to new ideas, techniques, practices, etc, than you are not doing yourself any favors and your professional growth will eventually be stunted.

You're completely entitled to your opinion Squint and I respect the fact that this is a procedure that you may not be comfortable doing. I also understand that it is not generally used in neonates and I would never use it on one myself. I think their lungs are too fragile and they are infrequently paralyzed even on the HFOV or Jet ventilation. However... you may not have heard of it but it is done in certain situations to prevent lung de-recruitment. It is not a benign procedure and certain conditions need to be met. The patient cannot be breathing spontaneously, the clamp has to be well padded with either plastic or rubber tubing or gauze so as not to damage the ETT and you have to be cautious that there is no breath stacking which could cause barotrauma when you unclamp again. It is not a common procedure but it is more widespread than you realize. It is most frequently used with HFOV but can be used with regular ventilation when the pt is on high levels of PEEP and does not tolerate the loss of lung recruitment. It was ordered by the Intensivists in my old unit. I don't advocate that it be used lightly but I have used it in the transport environment when I have had a sick respiratory patient with good effect. As long as you prevent any breath stacking and the patient has no spontaneous respirations then all you are doing in effect is doing an inspiratory hold procedure. It takes no more than a second or two if you have everything properly set up to do it. It is not without risk as I said. The whole concept behind Critical Care Transport is to transport critically ill patients to a higher level of care (generally). It is not in the best interests of the patient to leave them in a facility that is not equipped or educated to deal with certain patient populations. That necessitates transporting patients who may not be as stable as you would ideally like them to be. It is also not in their best interests when you do have to take them into a less controlled environment such as transport to not optimize their condition as best you can to allow them to deal with the added stress. Such as loss of lung recruitment in a pt that does not tolerate it very well. Then you compound the problem by having to take them to altitude and add numerous other stressors on them as well. One other problem with many companies in the transport world (except some specialty teams) is the fact that we only have self inflating bags (with added PEEP valves) and these are way less than ideal for use with critically ill respiratory patients. I will take the flow-inflating bag from the sending hospital but you do have to be trained in their use so it is not something I would recommend unless someone has that training. However when possible I prefer to maintain them on the ventilator and only have it available for emergency use. Unfortunately I do not have any literature on any kind of study performed re clamping the ETT but you can find numerous references to it in various powerpoints and other studies. Basically if someone is not comfortable doing it and really do not know what they are doing with the procedure I also wouldn't recommend it. However I will reiterate that it is done and it is done to prevent loss of lung recruitment. Cheers!

Yes this is done for that reason however you have to be certain the patient is not breathing at all on their own because if they try to take a breath while the ETT is clamped you can cause severe flash pulmonary edema. The tube is usually clamped at end inspiration as well just FYI.

California EMSA might help you get started or give you an idea. If not there are some contact details that you could try contacting them directly to see what you would need to do. Good luck and I hope you don't get too frustrated in California as unfortunately it is one of the less progressive and most confusing states for EMS in the U.S. (From what I understand!)

Without giving any medical advice since I agree with CH on that, I can say that oxygen is a pulmonary vasodilator which is why it causes some relief with pulmonary hypertension. Adam with pulmonary hypertension the pulmonary blood vessels become constricted, hypertrophied or fibrosed from numerous possible causes. This means the heart has to pump faster to get the same amount of blood through the lungs that the body needs which is why the heart rate is high. (It can also be from right ventricular overload and hypertrophy.) Giving oxygen doesn't increase the amount of oxygen to reach the blood because the problem is on the perfusion side not the ventilation side. Hypoxia causes vasoconstriction and oxygen causes vasodilation which allows more blood to flow through the lungs.

I would go with Rocuronium and Etomidate and avoid Succinycholine because of the risk of hyperkalemia with his muscular neuropathy. (You could also use vecuronium but Roc is my second choice after succs because it has a quicker onset.) They were good questions Lone and I would have asked them also but you already had. I just went on a more global picture in the end. Happy New Year everyone!!

I'm going to have to go with GBS over AAA as I think it fits more of the symptoms. The back pain is not the most common symptom but a deep aching back pain can occur.

Pretty cool! I hope it's not too expensive......because I NEED one!!! (I admit it...I am a Gadget Geek!) Not for work use since we have better monitor's available but I can think of situation's with family and friend's (and myself) where it would be fun or of benefit. Actually I had a situation on an airplane where the passenger was unresponsive and bradycardic. Of course they didn't have even an AED or any other equipment or medications so wasn't much I could do anyway. Thanks for the info. I'll keep my eye out for it.

I agree with Bilevel NIPPV over CPAP and that is what I would automatically apply. However most ground crews who are lucky enough to have access to any form of NIPPV often only have CPAP without the PS available. Semantics really. If my other treatment plans had failed to raise his SpO2 above 90% then yes, I would have gone for intubation (note I said if all else fails I would RSI/intubate). I would have tried NIPPV while setting up for intubation if draining the abdomen and NRB wasn't helping. Luckily he has improved with his SpO2 so I would put it on a back burner but be prepared for it. I don't intubate on respiratory rate alone but failure to oxygenate is a pretty good indicator to intubate in my experience. I would rather intubate when they hopefully still have some reserves left than wait until they have nothing left and have them code on me. Other advantages would be to decrease the overall stress levels and hopefully help mitigate a little of whatever is causing his distress - respiratory, neuromuscularly and hemodynamically. I don't think I would treat his BP at this point until we have a better idea of what is going on exactly. I would give him some narcotics and a little sedation though which should help the BP anyway. (Thinking aortic aneurysm/dissection still). I was not suggesting a blood clot embolus either rather an atherosclerotic emboli or multiple, one going to the lungs and one going to the spinal arterial supply causing an infarct. However he has improved slightly with O2 which may or may not rule out a PE in the lungs. The fact that his lung sounds are clear leads me to think it is not CHF in nature. I know he has a history of CHF but I don't think it is causing his dyspnea right now. His dyspnea could just be related to significant anemia as well. I would still keep pernicious anemia as a DD despite the lack of any obvious GI history. It can cause dyspnea and paralysis. At this point I am still treating supportively rather than a specific diagnosis. (Of course I would not be hanging around on scene trying to figure it out. Let's hit the road, Jack!) The lower back pain is still keeping AAA/Dissection at the top of my list. Of course there is probably a totally different diagnosis that hasn't been brought up yet. Thanks for making me think Dave.

I have to disagree here, Squint, even though the lower back pain is putting it low on my list, GBS is still a differential dx. It can have a rapid onset of hours to days or weeks. It can also cause clots and autonomic dysfunction leading to labile hemodynamics. It may have a low mortality because you can support pt's through it with assisted ventilation when necessary but if it has progressed to this point undiagnosed it constitutes a medical emergency none the less. I have cared for a number of patients who had long ICU stays with mechanical ventilation and not all of them were a slow onset to respiratory failure. Besides if the patient is in respiratory failure I would not be waiting for a bedside spirometry test for a diagnosis before I intubated them. I am leaning more towards a AAA/dissection scenario though because of the significant back pain with possible abdominal aortic atherosclerosis causing a pulmonary embolus. His co-morbidities definitely muddy up the picture. He could have paralysis from a spinal clot or motor neuron dysfunction. P.s. I don't think we would have the luxury of an ABG in the field! So definitely high flow O2 (NRB). I would drain the abdomen and see if that helps with his respiratory status along with the O2. If not then perhaps some CPAP with (depending on his BP- Do we have one, Dave?) some narcotics for pain control and sedatory effects for the CPAP. If all else fails RSI and intubate. 2 IV's with fluids TKO until we get a BP reading and a better idea of what might be going on here. 12 lead on the way to the hospital. Hope your shift's not too busy, Dave!

Hard to palpate for an abdominal mass but any bruits heard? I'm now a little concerned about a AAA or possibly abdominal aortic atherosclerosis which could also have thrown a clot to the lung.

Very interesting pt. Could we get a set of vital signs? I am leaning towards some kind of autoimmune response possibly from the infection or the medications. I am not sure that Pernicious Anemia is an autoimmune disease exactly but it would explain some of his symptoms: anemia coupled with a history or CHF causing increasing dyspnea, burning sensation and progressive weakness of his lower extremities (a worrying sign), his pallor and the diaphoresis. Another possibility is Guillain Barre syndrome but they usually have an ascending paralysis and possibly pain versus burning and numbness. The respiratory distress in GBS usually comes from paralysis of the respiratory muscles versus the dyspnea that is described here. Any GI problems or abnormalities with his skin?

EMTAnnie, I apologize if you thought I was attacking your post. That was in no way my intention. Yes, I think it is very important to learn rhythm analysis, cardiac anatomy, etc and I am sure that the book you suggested is very helpful for that. However there will undoubtedly be an updated version of the same book coming out very soon which will have all that as well as the new guidelines. It just doesn't make sense to pay $20-30 for a book that we know is already outdated when if you can wait a little longer you can spend the same money and have a current edition. There are also plenty of books just on rhythms and A&P that you can buy that will not become so quickly outdated. If the OP has an exam coming up and it is on the current guidelines then they may need to spend the money now. I am simply suggesting that if they can wait it will save them money in the long run. I would recommend the ECC Handbook with the 2010 guidelines. These books are pocket size and have lots of info as well as the algorithms. 2010 ECC Handbook While the 2005 updates had some more radical changes such as the CPR ratios and some medication and recommendation changes, overall there was more tweaking of guidelines than a more radical overhaul. The new guidelines have changed the whole process of BLS around so it is going to be slightly more of an adjustment. All the previous version had emphasis on A-B-C, now it is switched around to C-A-B which requires us to completely change our mentality of how we approach CPR. And don't get me wrong, I am not implying that we will have difficulty adjusting our thinking just that for a new person learning algorithms it can be a little confusing to have 2 completely different approaches to learn and unlearn at the same time. Especially when they are still learning the basics.

Please don't take this personally but (I couldn't resist ) ...seriously? Happy Holidays to all (including Xmas, Hanukkuh, New Year's, etc)!! p.s. I guess Lone has been enjoying too much eggnog!

I would not recommend spending too much money on any of the current guideline study guides. There are new ACLS protocols out and they will start teaching them next year with some major changes. If you can wait for a new protocols class that would be ideal but if not, don't waste money on the current study guides that are available. They are already outdated and you will have wasted your money. Here is a quick summary of the changes coming: CHANGE * Trained rescuers should change BLS sequence from A-B-C to C-A-B * Chest compression rate should be GREATER than 100 beats per minute * Chest compression depth should be GREATER than 2 in./5cm. * Untrained rescuers should perform Hands-Only CPR DELETE * "Look, listen, and feel" for breathing is no longer recommended * Atropine is not routinely recommended for all PEA or Asystole cases ADD * If available, continuous quantitative capnography is recommended throughout the peri-arrest period to assess physiologic change * Adenosine is recommended for stable, regular, monomorphic wide complex tachycardia * Post-cardiac arrest care including PCI and Therapeutic Hypothermia when indicated I think it may be slightly confusing to expend a lot of energy learning something and then very soon have to unlearn it or change your mindset on certain things.

Ok, I am going to bite and have managed to have enough willpower to resist Googling or reading the Medscape article so bear with me! I used to receive Medscape's x-ray presentations but for some reason no longer do. Good incentive to sign back up and also get these presentations as well. I was also leaning towards an autoimmune disease or an exotic viral or parasitic infection but you seemed to be under the impression that he might be more of a homebody or "non-traveling type person". I am not 100% sure if Lupus is an autoimmune disease but it does fit this picture. The elevated ESR is usually a sign of inflammation and is often elevated in arthritis and sepsis. The history of intermittent fever, weakness, malaise, weight loss, joint swelling and nausea can all be symptoms of Lupus. I think with Lupus it rarely presents with the exact same symptoms in any 2 people which can make it a challenge to diagnose sometimes. I am also looking at the anemia and the high end of normal BUN and Creatinine along with slightly elevated BP as signs of early kidney involvement. Elevated BP could also be attributed to the swollen and painful joints. I have taken care of a number of children in the PICU with kidney failure from Lupus. I don't recall if Lupus has specific "triggers" but he has a pretty complex medical history and multiple possible triggers for an autoimmune disease. The pale nail beds could be a sign of anemia but they could also be mild Reynaud's Phenomenon which can be associated with Lupus. Any chance he had a "butterfly" rash on his face? Now that I have contributed my 2 cents (Cheat free!!! ) I am off to find the article and see how far off base I am! Thanks for the brain exercise, Dwayne.

Since I was responding to your initial comment on beta-blockers being a no-go I don't see how you made the leap that I was advocating BB's as pre-hospital treatment. Having reviewed the COMMIT trial and a large number of other trials and recent (=/> 2005) literature reviews however, I will stand by my opinion that there is not enough evidence that BB are a complete no-go. Yes, there definitely needs to be caution in their use but looking at tachycardia alone is not a basis for giving or withholding them. Although a significant variable, tachycardia is not an independent predictor of the development of cardiogenic shock. It does need to be assessed but as a risk factor by itself a pt has a <1% chance of developing shock. (GUSTO trials). One study shows harm and the next one shows benefit so I will withhold judgement until there is enough convincing evidence either way. We all know how statistics can be manipulated to support individual agendas. I will add that though I would like to put a lot of faith in the COMMIT trial since it is a very large study, that having done medical missions to some of these countries my faith in their level of medical excellence is a little lacking. It would be good to know the level of medical care that goes along with the trials in general. It's easy to say we are going to do a trial and this person will have this drug and this one a placebo, when at the same time basic infection control is sadly lacking (not saying this is the case in all Chinese hospitals, just would be nice to know exactly what conditions were like in the included hospitals) it can have a huge influence on a study. (Just saying.... ) Thank you for the information on Plavix. Seems to me that there are way too many patients who are overtreated with antiplatelet and anticoagulant therapy in that they are not just given one medication but multiple. Then surprise, surprise we are called to transport them with significant head bleeds...now that has to mess with morbidity and mortality outcomes!

The effects of aspirin are twofold. The most beneficial effect is the anti-platelet aggregation effect which stops further clots from forming and prevents the problem clot/s from increasing in size. The other effect of benefit is it's anti-inflammatory effect on the already ischemic areas of the heart. What it is not, is a clot buster (technically)! A clot buster would be a fibrinolytic agent that actually breaks down the clot such as streptokinase, tPA, alteplase, reteplase etc. My understanding of the CRUSADE study is that Morphine worsens outcome in patients with CHF but it is still the preferred drug for ACS (without CHF). I like to give Fentanyl in ACS but it there has not been a study comparing Fentanyl to Morphine in ACS as far as I am aware. So at the moment AHA recommends Morphine for chest pain in ACS. AHA guidelines do recommend starting oral beta-blockers in stable patients in the first 24 hours after presentation. I wouldn't be so quick to say that beta-blockers are a "no-go". Rather that they may not indicated in the early, unstable phase of an ACS. Since there seems to be a number of studies saying that they are beneficial I think that the question of there benefit:risk is still undecided at this stage. "Even if beta-blockers have no immediate effect on mortality," Dr. Fonarow explained, "it is still worthwhile where it is safe, well tolerated, and given appropriately, to start them early, since many patients with MI may only spend 2 or 3 days total in the hospital. When you start therapy early in hospitalization, it's more apt to be continued and remembered at discharge and patients are more likely to continue on it long term." http://www.thedoctorschannel.com/video/2866.html?specialty=8 Paramagic would you mind posting the studies that show clopidogrel causes more harm than good? I would be interested in reading them.

By intranasal tube do you mean like a nasopharyngeal airway or NPA? (That would be completely different to and NGT or nasogastric tube which goes all the way into the stomach.) Does INT have another interpretation because if it means an NPA it doesn't seem to fit in another thread where it was used? (I took it to mean something like a saline lock.)

Thanks for your kind response. I think what I was really trying to get across is that people can critique in a respectful way without necessarily being so "gentle and kind" that it is basically ineffectual. It is just showing simple respect to each other and I am not accusing you of being disrespectful just generalizing. Sometimes it is a simple matter of putting yourself in the other person's place and realizing that a mistake may be made because of simple lack of knowledge and just requires education to fix (just an example). We also all have our off days and just miss things or have "duh" moments. I'm usually much harder on myself than anyone else is so when people talk to me in a disrespectful way it just tends to make me defensive and not receptive to their feedback. It's like telling a child that they did something that was bad (or wrong) not that they are a "bad boy/girl". That's what I meant by making it personal. I also understand that there are certain times in our field when you can't be worried about how someone will take a correction especially when there are pt's at risk. That's why we have debriefing. I think though that when people are willing to post on forums they are actively seeking to better themselves and further their education and agree with you that hopefully they won't scare off easily. I would hope that people would be willing to step up to the plate and continue to educate themselves if someone provides them with constructive criticism. I find that there seem to be too many newer folks who think they have all the answers and are not willing to ask questions and look for feedback. Perhaps you could call it a "surfeit of self respect". That is why I don't like to be unnecessarily harsh when someone is truly looking to increase their knowledge and willing to learn from more experienced folks. Nurturing doesn't have to be all frills and flowers. I find I am way more willing to ask someone questions when they are actively interested in teaching me and treat me with simple respect without making me feel small for asking. "Tongue in cheek" or face value???? I honestly appreciate the way you interact with people on here and applaud you for your efforts in educating others. I am often guilty of having my written word misinterpreted as it is very hard to get the correct tone across sometimes. People often misunderstand my spoken word anyway and totally miss my dry humor! Sorry to have hijacked the thread....and now back to our regularly scheduled responses...... Cheers and Happy Holidays to all!

Actually I have to agree on that one. I did find that one distasteful but was easily distracted by the length of the post!

[quote name='Happiness' timestamp='1291934136' post='250426' Why do you have to 'put your two cents in'.. but it's only a 'penny for your thoughts'?

I don't know if this has been posted but I got a good laugh out of it. It's a good thing to not take ourselves too seriously sometimes! http://www.youtube.com/watch?v=YzYxz_uvtSI Or just in case that doesn't work, here is the link: Freeway Patrol Cheers!

Educate me....what does INT stand for?

I am not sure I explained myself to my satisfaction but it will have to do for now. I am probably just a little too sensitive to QA processes at the moment and reacted more to how the post came across than the intent of the post. Cheers anyway, Aussie