chbare

Looks like we nailed the cause. What is going on with this guy? Take care, chbare.

Agreed, rhabdo is a problem. Look at all the problems we have: 1) History of catecholamine use 2) High doses of diprivan 3) Most likely some inflammation from trauma and surgery 4) Renal failure and rhabdo 5) Metabolic acidosis Can we make any connections between all of these concepts? Take care, chbare.

Diprivan for at least 48 hours. What are we thinking? Take care, chbare.

Could something else be causing the acidosis and myoglobinuria? While this is all related to the trauma (if he was never hit by an IED, he would most likely not be in this position), could something else be causing these problems. His H&H is a bit on the low side; however, lets say it has stabilized and there are no indications of ongoing hemorrhage or coagulopathy. This is a tricky one. Take care, chbare. EDIT: SANDMEDIC, most of what I do in the sandbox is typical primary care stuff with an occasional medical evacuation and commercial escort evac thrown in for variety. I still hold a part time position at an ER and with a flight service in the states where I plan to work while on leave.

IABP and Swan Ganz are different. IABP is a counterpulsion balloon device placed in the aorta to augment output, coronary perfusion, and decrease myocardial work load. In some cases, you may use an invasive waveform and information to guide IABP setup and settings. Swan-Ganz is a catheter that typically sits in the pulmonary artery and is used to monitor various parameters and calculations. My old flight gig have me using a CV4. Really liked the device, however, one big disadvantage is the fact that the CV4 cannot function without a compressed gas source. Currently, I have the Oxylog 2000. Not sure what to think as I have not used it on a patient. It is a very popular ventilator over here however. All of the ISAF hospitals appear use this device. Apologies for the digression. What do you think is going on? Is it even directly related to the trauma? Take care, chbare.

XII lead: Sinus tachycardia without ectopy or conduction abnormalities. No apologies, good discussion. Let's say you are able to rule out the typical MUDPILES as the cause of your anion gap acidosis. With the information available, where are things pointing? Somebody may have already mentioned the cause; however, I want to see what everybody else is thinking. What about the elevated CK and myoglobin in the urine? You can have your fentanyl and make any vent changes you deem appropriate. The patient is not currently on any PEEP. Take care, chbare.

You can manage the ventilator how you see fit. You notice he was given doses between 500-750 mg/hour of diprivan in the OR. Currently, his diprivan drip is set at 50 mcg/kg/min. No analgesia has been given. No way to monitor CVP or SvO2. Blood pressure remains unchanged. Hbg: 11 Hct: 34 Take care, chbare.

No coags available. However, you do note that he required rather high doses of sedation while in the ICU. Take care, chbare.

Good question; however, the sending facility made the changes. Any other information we can obtain? In addition, are we sure this is sepsis? Take care, chbare.

Patient is 70 kg. SvO2 is unknown. CVP is unknown. Total respiratory rate is around 22. Take care, chbare.

Ok, you load him and begin a long flight. You continue his infusions per the sending facility.( Dopamine and diprivan ) His liver was hit by shrapnel and bowel perforation was not really suspected. Flat plate is unremarkable. No air fluid levels, air under the diaphragm, or any indication of intestinal trauma. Your limited labs show the following: CK: 3,000, Myoglobinuria, and creatinine of 2.8. Anion gap of 22 is noted. Take care, chbare.

As SANDMEDIC noted, the patient is clearly in an acidotic state. What if I were to thrown in a serum lactate of 6? What does this tell us? The ABG was performed about an hour ago. The patient was initially on a FiO2 of 0.8 when the ABG was drawn and the vent rate was 12. Can this relate to our ABG? Changes were performed after the ABG results. Unfortunately, the labs are missing and lab cannot seem to find copies. However, you have limited diagnostic abilities on the plane. Time to get going. Take care, chbare.

Current ABG: PH: 7.3 PCO2: 28 PO2: 240 HCO3-: 15 Non Contrast CT of the head is negative. He is currently on a diprivan drip. His hypotension occurred in OR and was controlled with dopamine following blood products. He remains on a dopamine gtt at 10 mcg/kg/min. Blood pressure has been in the 110- 118 systolic range over the past 24 hours. Pancronium would be great at making him look sedated; however, there is the problem of actual sedation. Take care, chbare.

He is a 42 year old male with no known pre-existing medical or significant surgical history. He sustained a shrapnel wound to his abdomen in Afghanistan, was stabilized with blood products at a small facility and transferred to Emergency hospital in Kabul. Four hours S/P injury, he was taken to theatre and his liver was packed with hemostasis achieved. After approx two hours in the OR, he was evacuated to a hospital in New Deli the same day. After evac, he was admitted to an ICU. Your team makes contact approx 48 hours S/P injury. Additional Information: The patient had a hypotensive episode in the OR and was placed on a dopamine drip following blood product administration. He was not taken off the ventilator and remains intubated and sedated. He has had continued episodes of hypotension with several episodes of non sustained ventricular tachycardia. The ICU staff suspect an intra-abdominal infection. He receives Flagyl 500mg twice a day IV and Ceftriaxone 1000 mg IV once a day. Urine output is approx 10ml/hour. Current Vital Signs: P-115, B/P- 116/088, RR- 10 Ventilator, SPO2- 98%, Temp- 98.9 F . Chest X ray looks clear, surgical wound is dry and intact, without redness or discharge. Cultures are pending. Vent Settings: Vt- 500, R- 10, FIO2- 0.6, PIP- 21, Pplat- 18, I;E- 1:2.2, Mode: what ever you want. Take care, chabre.

Your critical care transport team is called to perform an international medical evacuation. Your patient is currently in New Deli India. You will fly him to Dubai UAE Wellcare hospital for ongoing treatment. The current working diagnosis is sepsis. You should expect at least a six hour flight. What do you want to know?

Perhaps we need to define the topic of scope of practice. My SOP as an RN is dictated by the state BON and in most cases SOP is rather vague and broad. So, I really have a difficult time relating to all of this breaking protocol talk. With that, I guess we are talking about Third Watch drama stuff? Guy rolls his car, arm is pinned, the flames are coming closer, his pregnant wife and crippled little daughter are begging you to do what needs to be done so daddy can come home? This may come out sounding very bad and some of you may not have respect for my opinion or me after this; however, here goes: Medicine is my lively hood. I have never had any other job. (Other than bagging groceries for a while in High School.) I only know this one area. This is how I make my living. This is how I pay my bills, ensure my wife and I have a house, food, transport, and medical care. This is in part how her daughter was able to attend college and prosper. A few years back, my wife had a serious medical problem. Because of what I do, my insurance package, and the money I make, she was sent to a specialist. One of the best in the field. Now, she continues to live a full, healthy, and happy life. I need to continue to do what I do to ensure this continues. You see, what I do and the consequences of my actions effect so much more than just my self. I am always going to ensure that I can take care of my family and my self first. Is this not why they preach scene safety and security in our courses? Are we not number one? When did this concept change? I would have to think long and hard before I potentially throw my life and my families life away on performing a technique that I am not educated to perform.

Cannot believe I have been asleep so long as to miss this one. I have to go with the general direction on this one. Some of the situations I have seen so far include; IV therapy, epinephrine for anaphylaxis, and treatment of pre-eclampsia. Look, if you as a paramedic work for a service where you have to obtain permission to place an IV or give epinephrine, one of two concepts exist. 1) Your medical director does not understand EMS. 2) Your medical director does understand but is fearful of letting a paramedic perform an intervention under the physicians license. (Not difficult to understand with some of the educational standards.) Either way, this means your service sucks and you should not even be working for such a place. Problem solved. Take care, chbare.

With Sux and burns, I suspect we are concerned about hyperkalemia? This is not usually a concern immediatly following the burn. After the first 48 or so hours it could be a problem however. I have used Roc as an alternative with good results. More recently used it on a hyperkalemic patient in acute renal failure, among many other problems. One thing to always file away is the possibility of severe allergic reactions to NDNMB's. Especially now that roc seems to be drug of the year in the USA. Now that sugammedex is on the up and up, who knows what will happen with the NDNMB market. Take care, chbare.

I agree. Etomidate is a very good agent for RSI. Rapid onset, fairly predictable duration of action (around 100 seconds for every 0.1 mg/kg), and hemodynamically stable. Of course there are cases of masseter spasm and adrenal suppression; however, every medication has risks and benefits. I think propofol has a place; however, it is a very fickle medication and can precipitously drop blood pressure. Not a great situation with a head injury. Fire, thanks for the heads up. I am not really a fan of this sedation intubation technique. A major reason we use a paralytic is to prevent aspiration. In EMS we have to assume none of our patients are fasting and thus need to proceed with the expectation that our patients are at high risk for aspiration. Of course, we have the added benefit of better intubating conditions when a paralytic is used. Snowing somebody until they can take a tube really is not an optimal situation IMHO. If a special situation exists such as a predicted difficult airway, then an awake technique such as nasal intubation may be considered. Take care, chbare.

What is RSS? Take care, chbare.

Well, there is some evidence that preventing fasciculation's will blunt ICP changes and prevent post-operative myalgias. Typically 10% of a full paralyzing dose of a NDNMB is given prior to your dose of Sux. I liken this to using lidocaine on head injuries. Not much definitive evidence that says it is particularly helpful. Agree that if you plan to defasciculate, you should be set up and ready for intubation prior to pushing a defasciculating dose of NDNMB. As far as people "waking up" and starting to breath. I do not advocate for such an argument. We RSI patients to secure a compromised or potentially compromised airway with the hopes of preventing aspiration. So, we already have airway issues. In addition, we need to remember that a phase II block and prolonged paralysis can occur with Sux. We cannot expect every patient to develop spontaneous respirations following induction and paralysis. This is especially true with compromised patients. I agree that premedication with an opiate prior to induction and paralysis is good practice. Personally, I like to use fentanyl. Take care, chbare.

ROTFLMAO Take care, chbare.

http://www.fieldmedics.com/forum/viewtopic.php?t=2255 Take care, chbare.

Please, take some time to actually read and comprehend Dustdevil's posts. He has always argued against the level of education and against having basic EMT educated people caring for patients. Nothing personal, just how he views the situation. I hope some day you will be able to appreciate his stance. Tae care, chbare.

Oh the memories. I dated a girl in high school who had several birds including a large Mccaw. The bird would scream out names of the various family members. I remember the first few times I heard that thing scream were a bit spooky. Take care, chbare.