chbare

GCS of three and unawareness are not mutually exclusive concepts. Many conditions can produce a GCS of three, while the patient may be awake, aware, yet unable to communicate. Take care, chbare.

ARDS is always a consideration in these types of patients. The problem is in fact compartment syndrome. Abdominal compartment syndrome to be exact. What could have caused abdominal compartment syndrome? Take care, chbare.

It sounds like a judgment call. Too bad you did not have etomidate, as this could have been a good agent for a similar call. Also remember, many people say that in some situations you can utilize a paralytic agent without an induction agent. Some "crash airway" guidelines allow you to perform such a procedure. Remember, your patient must be unconscious and near death to meet most definitions of a crash airway. Not every crash airway will require a paralytic; however, specific cases could be managed in such a way. Prior to heading over seas, I helped out in an ER with a person experiencing a massive overdose of narcotics. He was unresponsive and circling the drain; however, he still had intact gagging. The doc was actually very good and declared a crash airway requesting sux and a double airway setup. We were able to intubate without difficulty. So, in specific situations, this is a viable route to consider. Take care, chbare.

Cheers mate. I will look you and AK up if I ever visit your neck of the woods. Take care, chbare.

No college level anatomy and physiology, English, or math requirement. Take care, chbare.

Need to consider serotonin syndrome. Physical exam, neurological status, temp, and XII lead? Any sudden changes in medication routine or dose? Take care, chbare.

Agree, the safety and side effect profile of demerol can be concerning. Again, I still think fentanyl is a good alternative to morphine. Take care, chbare.

Again, pain management should be the primary goal. If we are concerned about blood pressure, I see no problem with fentanyl. I am not sure that the said patient "needed" MONA. I think the OP took a conservative approach. Blood pressure was borderline and the OP made a judgment call. I will take a step back on the V4R. It looks like one was performed showing changes. However, it does not sound like RVI was definitively confirmed. This is good practice and gives you additional information to base your decision making. I agree that fluids are helpful if no other problems exist. Holding off on NTG while giving a fluid bolus is not a bad call IMHO. However, saying somebody "screwed up" for holding off on NTG with the said pressure? Your heart loves hypotension and crap coronary perfusion pressures, especially when it is infarcting. Why would demerol be a better agent for pain control in the said patient? Why would demerol be a better choice over fentanyl? Take care, chbare.

Yeah, I had a vision of the monkeys throwing their poo at another monkey because he was doing something they thought was different. "Every MI patient needs MONA ya know. Why? Because we give every MI patient MONA." Take care, chbare.

Hu? :scratch: Take care, chbare.

Good job everybody. I think people realized the cause pretty early on in this scenario. However, I wanted to discuss things further before giving the cause away. Initially, we were presented with a trauma scenario; however, additional investigation led us to suspect other problems than a simple fall. During the patient's course, he in fact develops rhabdo and has continued hemodynamic instability. Fluids along with pressors are needed to "stabilize" his pressure. After the first couple of days, he ends up developing compartment syndrome of the extremities and require surgical intervention. You have him "stabilized" in the ICU following the said interventions when you note decreased urinary output and increased ventilatory pressures. What do you think? Take care, chbare.

Did you perform a V4R? This is about 90% specific and sensitive to the detection of right ventricular infarct (RVI). Inferior wall MI is not a specific contraindication to giving pre-load reducing agents; however, RVI can accompany inferior wall MI. A V4R gives you a better picture of the inferior wall MI patient and gives you ammunition when you decide not to give preload reducing agents. Because RVI patients depend highly on preload, giving agents that reduce preload can cause disastrous side effects. However, hypotension is somewhat of a no -brainer. Having all of your facts laid out and having the ability to defend your actions is a great asset. In addition, the mechanism of action related to morphine and blood pressure is due to the fact that morphine can cause the release of histamine. This is what leads to blood pressure changes with this agent. Fentanyl; however, is not associated with histamine release and is typically hemodynamically stable. It is a great choice for hypotensive patients. In fact, I just flew a non Q wave MI patient out of Afghanistan. He had inferior wall changes and positive cardiac markers. Developed hypotension on an isosorbide drip at the sending facility. In addition, he had hypokinesis of his inferior wall and right ventricle when looked at via echocardiogram. He was experiencing a great amount of pain. After a fair amount of fluid and a few hundred mcg's of fentanyl, he was much more comfortable and had a higher blood pressure. This was good because we had a six hour flight. So, IMHO, fentanyl is a great agent in some cardiac patients. Take care, chbare.

GCS: 3 No spontaneous respiratory activity. Unable to obtain a pulse oximetry waveform. ETCO2 is currently 28. Hard to get a pressure in the other arms as it is obviously deformed mid humerous. Clear lung sounds with equal bilateral chest rise and fall noted. Skin is pale. BGL: 112mg/dl Additional assessments are unchanged from the findings stated above. Current pulse is 120 weak and irregular at the carotid. You note approx three to four 7 complex runs of unifocal ventricular tachycardia per minute. How much fluid will we give? Lidocaine versus Amiodarone? What do you all think? Still waiting on a scene update. Labs: WBC: 15 HBG: 15 HCT: 45 NA: 133 K: 5.4 CL: 102 BUN: 30 Creat: 3 Myoglobin: 570 CK: 1000 CKMB: Pending Trop: Pending What do you want done at the ER? Take care, chbare.

Weather is sunny and boring blue. Your partner seems a bit concerned about the patient's pressure, or lack of pressure in this case. Take care, chbare.

Patient is unresponsive. Saturations were in the high 90's. You are not able to obtain a pressure or note a pulse oximetry wave form. A weak carotid pulse is noted however. Unknown history. The blister and skin redness appear "new." The redness resembles a sunburn. Take care, chbare.

You note a large reddened area to his left foot. In addition, his pupils are 5 mm and sluggish to react bilaterally. Otherwise, the exam is unremarkable with the exception of the findings previously discussed. Take care, chbare.

What about his vital signs and runs of ventricular tachycardia? I will let you guys have labs; however, do we need to consider additional interventions while waiting? Take care, chbare.

If hyperkalemia, what is the cause? Are you going to treat for hyperkalemia? Take care, chbare.

You place an IV lifeline. A reservoir is attached to the BVM along with flush oxygen. You note sinus rhythm with frequent runs of non sustained ventricular tachycardia upon performing a quick look. Your partner obtains a blood pressure of 70 systolic. You manage to catch a XII lead and it is noted below. The blister is on the posterior aspect of his hand. The scenario is based on a patient I saw in Afghanistan. Take care, chbare.

Who knows? For us to find out however. Remember, ETCO2 and PCO2 are different concepts. With that, I agree the aggressive ventilations may not be helping the situation. Take care, chbare.

You note equal chest rise and fall with sounds throughout. However, the first responder continues to ventilate rapidly. You initiate waveform capnography and note a plateau shaped waveform with an ETCO2 of 18. Additional findings include a small blister to his left hand. Additional assessment findings are difficult as he is still wearing clothing and equipment. You are unable to see any ECG rhythm as the AED is still attached. However, you not a weak irregular carotid pulse. Take care, chbare.

You are called by a first responder crew en-route to the scene. You end up intercepting a first responder vehicle. Scene size up shows a 20 year old-ish male supine on the stretcher. He appears unresponsive, apneic, and has gross deformity of his left mid shaft humerous. A combitube is in place and one of the first responders appears to be frantically and rapidly ventilating the patient through port number one. The responders speak very limited English. From what you gather, the patient was working on some sort of construction project, fell onto his left side, and was found by the first responder crew. The fall was approximately 20 feet. Again, hard to establish anything specific related to communication barriers. The patient was initially pulseless and an AED was attached and utilized. After one shock, the patient developed ROSC. The crew inserted a combitube after ROSC, loaded the patient, and initiated transport. Take care, chbare.

You are called to the scene of a fall at a construction project. Take care, chbare.

Huh, this seems like a no brainer to me? We are responsible for transporting our patients medications, ventricular assist devices, insulin pumps, Flolan pumps, and so on, why not grab the ashes and transport? Take care, chbare.

What is the problem? This is the United States after all, 16 is the new 30. :shock: :oops: Take care, chbare.