kohlerrf

Entidal C02 and waveform capnography is a must use tool for any pat in respiratory distress. There are volumes written about this and I suggest every medic bone up on it. we all lknow the limitations of ETCO2 especially in trauma but knowing knowing that its still usfull in trauma. To take it to the next step and to more fully evaluate the respiratory system we use pulsox in conjunction with capnography and interprete the figure together

I agree, the only 2 situations I can say the administration of specifically oxygen truly helped my pt is; 1)Arriving to the home of a patient on a home room air nebulizer giving themself an albuterol treatment. When I repeat this with 100% O2 off my D tank the pt seem to recover faster. You could say that this is just the effect of the previous medications kicking in, but I don't think so because over the years I have gauged reaction times with initial tratment on Oxygen and initial treatments using room air. 2) The second situation is, believe it or not, Oxygen is my initial drug treatment for un-complicated sinus bradycardia! and it works.

Limiting the discussion to the the standard Mac or miller blades, the blades are "shaped" to facilitate displacing the tung to allow for visualization of the glottic opening and the landmarks. if you are adept at intubation yes you could use the right hand and get the same result while crossing your arms (if your not doing an ice pick intubation), but wouldn't it be easier just to use a right handed blade?

Hey City senior thanks for the effort! Every day I learn how much I still dont know. I'll follow up with Physio. "MEME" great though process but remember you can have a O2 sat reading of >90 for several minutes in a patient with no pulse. I think the most intuitive thing you said and often most ovelooked is pt color.

The original question is a little vague with regard to efficacy. My personal indicators are actual perfusion pressure and output of the heart. admittedly based on numerous assumptions we were all taught that if you can get a radial pulse you can estimate the B/P to be at least 80 systolic. Likewise if the pulsox is picking up a clear regular waveform in the capillary beds of the fingertips that are suppled by the radial pulse of 80 systoliccthe same assumption of B/P can be made. The point being that a manual pulse taken with the excited finger of new EMT or Medic or for that matter a barriatric patient can and often is subjective and inaccurate. The pulsox does not have an excited pulse of its own and is completely objective. Barring patient movement poor connection etc... if the pulsox is detecting a "rate" there is expansion and contraction of the arteriole capillary bed caused by fluid under fluctuating pressure moving through it. In this case we accept the pressure is close to 80 systolic because we agree the minimum pressure to feel a radial pulse is 80 systolic. Again just a cascade of assumptions based on accepted teachings. Lastly and this cannot be stated enough, if you CANNOT get a rate from the pulsox you CANNOT assume there is no pulse. If CAN get a rate from the pulsox you CAN assume there is a pulse but of what exact pressure you can only estimate. I am unfamiliar with "C-Lock" could you explain what it is in a little more detail?

so we agree?

John, I think you took my comments out of context. I meant to convey the primary concern of the pre-hospital provider is the actual pulsing beat of a heart and secondarily the electronic wave form that pulse produces of which the Life Pak defaults to. ACLS 101 "any beat beats no beat" if you disagree with this then I think we have the beginnings of a whole new topic. Further more I was very clear that one should not chase the pulsox and follow the AHA guidelines of 100 beats per min. In support of my point you point out that regardless of the rate the efficacy of CPR is judged on the ability to maintain MAP in order to support cerebral perfusion. Although the Life Pak does have the ability of invasive blood pressure monitoring our does not. Since you point out and I agree the only thing that matters is to maintain the MAP, do you disagree with the premise that the most common tools we currently carry pre-hospital to estimate or map and therefore the efficacy of CPR is the pulsox and or the blood pressure cuff?

In answer to your question on how to gauge effective CPR, it was stated in a threat "Although end-tidal CO2 serves as an indicator of cardiac output produced by chest compressions". More specifically End Tidal CO2 serves and indicator of cellular metabolism, excretion and ventilation that momentarily may or may not have any bearing on cardiac output. However. The Blood pressure cuff and "Rate" function in the Pulsoximeter is the only device that I know, we carry, that is dependant on "cardiac output" in order to function. This brings us to a bigger problem, on of which I have been is discussion with Physio over the past year. It would be logical that during a cardiac arrest we would have the Life Pak hooked up monitoring the end tidal on the tube and the pulsox taped to the finger forehead or toe. If the rate function of the pulsox picks up a rate at the finger tips we know we have a B/P that approximates 80 systolic at what ever rate it indicates. If the pulsox is on the toe and reads, the B/P would be something higher. Understand that if we have a reading indicated by the pulsox, we have a fact, and can confirm cardiac output and its “effective rate”. Remember the rate on the pulsox may differ from the rate you are doing compressions, however the rate indicated on the pulsox is the “effective rate” at wherever the sensor is placed. If we don’t have a reading we can neither confirm or deny the presence of cardiac output. Further, it would be irresponsible and one should not “chase the pulsox” as increasing the rate or depth of compressions ,to get a pulsox reading, beyond the specific norms recommended by the AHA is bad and wrong on many levels. Pulsoximetry actually measure the expansion of a pulsing vessel with no regard to electrical activity and is definitive. I grew up on and started with the Life Pak 3. I am an ardent supporter of the Physio and as such was very disappointed. I don’t know if anyone has noticed that although the life Pak 12 has a rate function built in to the pulsox as soon as you hook up the EKG cables the “RATE” indicator on the display defaults to the Electronic Rate as read by the amount of electrical complexes on the screen or more simply the “heart rate and not the pulse rate”. When you unplug the leads it reverts back to the pulse rate providing you have the pulsox hooked up. As we in the field are primarily concerned with the pulse rate this is obviously and error and I have approached Physio on this and they have no answer yet. In addition the competition (who will remain nameless) has on their monitor 2 separate and distinct displays one for heart rate and one for pulse rate. This duel display is also helpful in detecting blocks or a brady with non perusing escape beats. In answer to the question, if one of the 3 displays on my Life Pak is tuned to Pulsox wave form and if a waveform is present and the sensor itself is motionless on the fingertip and I have no intrinsic EKG complex I can say my CPR compressions have a cardiac output with a blood pressure approx at least 80 +/- systolic. The NIBP is also effective in this manner as well. If the NIBP detects a B/P on the calf or arm during CPR it is what is it. Lastly the term effective needs to be clarified. Is the objective to be performing according the numbers in the AHA guidelines? Or to meet a consistent numeric pressure blood pressure value and pulse rate? If so what is min rate and more important the B/P to be effective?

If you dont make absolutely sure you have a patent line before you do anything IV then I think there is a bigger problem?

There is very good advice here and no need to recap it. 2 additional comments I have are that you might want to form a legal nonprofit organization. This allows you to use solicited donations for the expense of payroll, however with this comes an administrative load, including but not limited to selecting a board of directors, Bi-laws, monthly meetings, business plans, customer service issues, quarterly tax reporting, payroll insurance , workers compensation insurance, health insurance and benefits for employees and the list goes on. Remember, the list is not un-doable buy those that really want to be a paid service. Secondly, in your quest, remember you are pushing a service on the towns people that expend energy to deny they will ever need and every politician knows this. What politician in his right mind would run on the platform of "I’m Joe Blow elect me and I will get you ambulances because one day soon you are going suffer a horrible fate and need one!" I had your ambition 20 years ago when I was volunteering in a similar setting, although a little bit more urban. I had a discussion with a public official “off line” in which he asked me the following ; What do I think would cause more public outrage but the community, The volunteer ambulance not responding one time to a house 2 blocks away or the communities household garbage not being picked up this week? Lastly, as stated in another thread here, “If the town can get this service from volunteers for free now why do they have to pay someone to do it?” I applaud you for your ambition and urge you to follow through with it. In the big picture it is a proven fact that a paid service is more economical and “on average” has a higher standard of care and is definitely the way to go!

I recently had a centrally cyanotic 10 month old baby boy in Stat Ep refractory to Diastat in respiratory arrest, fortunately through RSI I was able to control the airway and the pt did not arrest, but, Yes, had the pt arrested and after I had control of the airway and done 2 min of CPR and ruled out respiratory causes and done what I could with metabolic causes and 5H's and 5T's, if I had a shockable rhythm and I had the proper size pads and a defibrillator where I could select a weight based charge and I had not arrived at the hospital yet, Yes I would defibrillate the still dead lifeless body in front of me.

We are moving away (in my servce) from giving a D50 bolus. We tend to opt for a D10 drip in NS or (D12.5 in D5W) unless the patient is so far gone there is repiratory compromise or the pt has been down for a subtantial time with a GCS of 3 and a dramatically low BG. The untoward lasting effects of taking a diabetic pt with a glucose of say 40mg/dcl who is semiconsious and disorented and bolusing them which results in a BG now of possibly 310 mg/dcl is well documented. Specifically regarding the question of D5W or NS. I dont think the issue has anything to do with the glycemic state of the patient. I reserve D5W for medicated drips, Dopamine , Cardizem etc... If I am concerned about fluid replacement such as in case of a hyperglycemic pt with poly uria/dipsia tachypnea and a normal End tidal CO2 I would opt for Normal Saline as it is an isotonic solutiion and would hold its water in the vessel. In a hypoglycemic patient who is not hemodynamically compromised I mix D10 in a bag of D5W (it actually come out to be D12.5 but lets not go there). In the case of D50 I beleive it all has to do with the hemodynamic state of the pt and not the glycemic as to your choice of fluids. Lastly you can always push D50 through a LOK then flush and not have to worry about all this?

I don't believe I have ever read or learned anywhere that a C Collar immobilizes the c-spin. In fact I have experience to the contrary. In trauma the C collar is probably the last thing I worry about the first is to dedicate one individual to hold manual stabilization and maintain and open airway a c collar can get in the way of a jaw thrust or selleck maneuver or a at worst case a cric. manual stabilization also can pull traction and prevent vertebra from rubbing together and allows us to maintain the proper orientation of the head to the torso during movement of the body until we eventually get the pt on the board. if there is a minimal or no possibility of airway compromise applying the collar can aid in stabilization but does not replace manual stabilization. In short C-Collars are an aid only, when you put them on is up to the circumstance and dont get caught not holding manual stabilization until your patient is secured head to toe on the back board.

CH brings a good point, particularly with trauma patients or even with CVA patients. In uncomplicated cases though, and even in more complicated cases an anesthesiologist will at times ask the surgeon to stop so he can lighten the patient up. “Lighten” meaning reducing the level of sedation momentarily to restore the normal circulatory mechanisms and to exercise the brain. The proven benefits short and long term to the patient have been proven. It must be remembered that a patient breaths for himself better than you or anyone else ever can. Although minimal, the respiratory system plays a key role in circulating not only blood but lymph. As we walk throughout the day our leg muscles squeeze our veins and the squeezing pushed blood through the one way valves back to the heart. However the larger vessels in the thorax and abdomen don’t have valves. During inspiration the diaphragm descends into the abdomen and the chest walls expand. This causes pressure changes. The thorax becomes a vacuum and the diaphragm pushing into the abdomen raises the pressure in the abdomen which compresses the inferior vena cava pushing the blood into the vacuum created in the thorax before pressure is equalized by the in rushing air. During the first part of exhalation the right atrium is now filled with blood and so the cycle continues. The lymph circulation is also aided in similar way. When a patient is intubated, apnic and being ventilated they never have this negative pressure(or vacuum)cycle in their ventilation and the thorax is always under positive pressure as you push air in to inflate the lungs and the thorax pushes air out to deflate the lungs. The state of being “snowed “and ventilated can only be tolerated with a supine pt with minimal cardiac demand for a short period of time. One very common problem on vented patients is a sudden hypotension cause by air trapping due to a poor I:E ratio or excessive PEEP. In general if a pt does not exhale fully with a timed vent or volume controlled vent air will be trapped by the incoming breath and over successive ventilations pressure will build in the chest compressing the vena cava and cutting of the blood return to the heart. While it may be comfortable for the practitioner to “snow” them to prevent arguments it is a dramatic departure from what the body was born to do. There are many many considerations to controlling the way somebody breaths as CH pointed out not the least of which is ICP. Yes you can get a way with drugging your patient and just pumping some air into them for your 20 min transport but with that mind set why waist your time giving morphine to a patient in pain if their not annoying you?

I agree there is no reason to check the mental status on a copd. I may have not been clear enough. I never fully wake the patient, as you pointed out this could cause unsafe fluctuations in ICP as well as other problems you also point out. I try essentially just to lighten them up to a state where the rate and depth of respiration voluntarily increase to like a level 2 dream state. Here is where Propofol would be great. I currently use versed, of the three it has the most rapid onset (some argue Ativan is faster). We monitor End tidal CO2 , respiratory rate and pulsox , pulse and BP when I see the numbers begin to rise I "check in" and then re-bolus with versed the pt goes down for another 10 min and never regains consciousness. I find it important to do this, as it allows the thorax to return to a negative pressure inspiration assisting blood return to the heart and maintains well perfused muscles of respiration making it easier to eventually wean the patient off the tube.

Pain Hurts ! Stop the Hurt !

I have no experience with Fentanyl however we use its lesser cousin morphine but only for pain relief and maybe in CPAP. Versed is my choice but only because we have relativly short transports. We generally use benzos or a hypnotic like Etomidate for RSI and to maintain sedation. Etomidate is nice however if not given with a bezo may cause myoclonic seziures. I am pushing for my service to get Propofol. I prefer to keep my intubated patient "light" and breathing on there own for numerous reasons and I feel Propofol would make this job much easier. Currently we carry Valium Versed Ativan Etomidate and Sux. While we never use Sux for long term, we do select our benzos according to length of effect among other reasons but as you pointed out we can’t maintain the blood level and consistent sedation with a bolus. In trying to reason out why we don’t have a drip sedation agent I believe it is because it’s a general practice to lighten up sedated patients every so often to "check in" and keep the body juices flowing. Having the ability for continuous sedation may cause complacency.

Im sorry you had a bad experience. From what you have said here it appears that you did not have a ventilator but instead you may have had a device delivering CPAP at too high a PEEP. With regard to "no moving the tube", currently our pt in respiratory arrest is often secured to a scoop with the "D" tank between their legs feeding the 3 ounce ventilator which is attached to side stream continuous capnography and the ballard then to the ET Tube. This simple assembly is then secured to the C Collar and tube placement is checked again, vent settings finalized and then the pt is moved. No one is bouncing around holding a BVM walking down stairs or in the back of the amb. the vent is fixed in place and moves with the pt only when the pt is moved.

I agree. This is not a fire and forget nor did I mean so sophomoric as to imply such a thing. As a matter of fact our documentation has to include trending of Sa02 and EtCo2 readings along with "graphical" waveform capnograph during the time the pt is on the vent as well as the corrections we make to coordinate the two. Vents are dangerous so are defibrillator's. I think the assumption should be that the practitioner is properly trained to use the equipment before they are allowed too. In addition, I agree this brand is not designed for long term transport of the critically ill with multiple co-morbidity's. It would be ludicrous to assume that this $75 piece of plastic replaces an actual Vent. We are using perhaps for 30 Min's during extrication from the home and transport to the hospital. it provides constant ventilation while maneuvering the patient around a tight corner and up a flight of stairs to the amb. removing the 3rd man who may have to drop the BVM for a moment while you turn a carry has proved to be advantageous in reducing the movement of the tube prehospital. It also facilitates having less people involved in touching moving and caring for the pt. As you said this can free up hands but it also focuses responsibility.

Rock I think you bring up a very good point. Too long have we been exposed to exhaled pathogens (it was TB in my day)and scooby, I think you offer a good "plan B" however the preferred is to not have air born droplets at all. I'm sorry I don't have experience with IV ventolin in addition I was always taught that nebulized and inspired it had its shortest onset and therefore sooner correction of the presenting problem. It may just be myth I don't know. I'm wondering if IV Ventolin is the best solution or having the practitioner put on an N-95 mask when treating a suspected respiratory infection? There are some inherent risks in our business.I am embarrassed to admit that when I started we never wore gloves and were sticking dirty needles in the bench seat cushion. In any event I'm going to start wearing our n-95's thanks.

My service is totaly ground based and for several reasons we are bringing into service a disposable 1 patient use oxygen powered pressure ventilator. We average 20 cardiac arrests a month and add to that, a number of RSI's. There are some very good advantages for the patient as well as the paramedic in their use not the least of which is that once the vent is set NOBODY TOUCHES THE TUBE EVER untill the doc in the hospital after you transfer the patient. The Vent we use is called the "VAR" or Vortran Automatic Resuscitator. Although I know this brand is used in Air Medical Services often, does anyone have any experiance using it in a ground based system for 911 patients?

Intubation is the gold standard of airway management in the pre hospital setting. It is a short sighted medic who is only concerned with ventilation. The real reason you intubate is to protect the airway! Pre hospital patients are not generally NPO before needing an ambulance. Bagging a pt might ventilate adequately however you will most surely spill some air into the stomach and eventually that air is coming back up and now we have real problems. Barring surgical procedures ET tubes are the way to seal off the airway from any vomit or other objects and maintain it. The king airway, obturators , combitubes I guess might be an alternative but they are cumbersome with more junk on them. More importantly they don’t address the problem. The problem is PARAMEDICS that are inept. Force MEDICS to learn the skill and be responsible and maybe the industry will move forward instead of backward.

IO in the humerus EJ very risky and low percentage