fiznat

Draw it in paint and post it up!

ROGER!

ECC stands for Emergency Cardiac Care, and is pretty much everything you do in ACLS (save airway stuff) that is not CPR. Just another acronym to remember, really. http://circ.ahajournals.org/content/vol112/24_suppl/ I'm not sure what AZCEP is getting at here either. Some quotes from the AHA ECC guidelines: It seems that much of the research shows that there is very little difference between the two drugs as far as patient outcome, so I suppose it makes sense that the drugs may be used interchangeably (in the method according to the guideline).

haha I'm here! Pretty busy lately but I'm always at least lurking...

We carry both at my service, and I think there are two reasons why vaso isn't used as much as epi: 1) My service buys vasopressin in 20 unit vials, which is a pain in the butt during a code because you have to draw up two vials worth of meds with a needle or blunt tip before you are ready to give the drug. 1:10,000 epi, by comparison, we have in quick-n'-easy 1mg jets. It is simply less trouble to use epi, and during a code that tends to make the difference. 2) Vaso is newer than epi, and truthfully I think a lot of medics are just used to the epi/atropine/lido regimen that they don't consider vasopressin when the time comes to make a choice. This isn't as much of an issue for newer medics such as myself, but even still I find myself using epi more often than vaso probably for reason #1. ...Actually come to think of it, I've never used vasopressin in the field. Maybe I will next time! haha

My preceptorship was about 2 months which added up to something like 150-160 ALS patients before I was "cut loose" to work on my own with an EMT partner. Still, I didn't really feel like I was getting into a groove until 6 more months on my own. It does take a while, and even then like others have said there will still be calls (often!) that shake you loose.

We've had this discussion a million times before in a million different ways, but my prejudice as a paramedic aside (if you will allow me that), I don't think any expansion in scope below the paramedic level is a step forward for EMS. Personally I feel we should be working towards higher standards, not blurring the lines between the already low standards we've got.

Yeah like others have said, CPAP tends to use up a lot of oxygen to power the device properly. To be clear, what size tank are you referring to? 2000psi in one tank is not the same amount of gas as 2000psi in another, differently sized tank. Did you really go through an entire M tank in 30 minutes, or were you using a smaller sized bottle?

I agree that there would be no point to THAT discussion. However, the original post says nothing about any assumptions that should be made about the equipment. You simply state "Suddenly, his arterial waveform flattens, and he becomes unresponsive." With as little information as there was there, I think it is prudent (as it most certainly is in real life!) to request a little more information. Don't get your feathers all ruffled, it wasn't an attack on you. Okay buddy. :roll:

Maybe I'm missing something here, but I'm not seeing anything that differs from the standard ACLS/PALS routine...? Interesting that they suggest applying an AED to determine whether the rhythm is shockable or not. It might be just me, but I might assume that if we have arterial lines and cardioactive drugs running, we might also have the patient on a cardiac monitor as well, and would be capable of determining the rhythm ourselves without the AED. As far as assuming pulselessness by looking at a monitor, you cannot do that ever... regardless of how well you might assume the equipment to be working. I guess its a silly argument though, so let's agree to disagree.

1) Get all your gear together, open your supplies up and position whatever means of transport you have near the patient. 2) Extricate the patient 3) Control bleeding the best you know how and move ass. There really is no other choice. If he really does have severed arteries, definitive treatment is surgery, not an IV line. Assuming the worst, you need to move towards that goal as quickly as possible.

No, it means only that the waveform is flat. We still need to check for a pulse and actually touch this patient to confirm that it is an arrest. Given that it is a code though, I'd still like to check the rhythm before we start getting into the shock/meds routine. ...And like I said, shut those meds off. Milrinone has a well-known potential to instigate ventricular dysrhythmias.

Definitely assess before we think about treating. Out of the choices I would like to know about the heart rhythm, but a full assessment is obviously in order. Is this patient actually pulseless? Is he aepnic? Is he completely unresponsive or is there a response to noxious stimuli? How well is he ventilating on his own vs with the BVM. Patent airway for now? Pupils, BGL, vital signs, etc, etc etc. ...Oh, and stop those meds for now.

I think that's reasonable. Our protocol only calls for "reactionary" antiemetic if you will, but in a case like this I think I would probably do the same thing. LOL I'm still stuck on that ECG. How the hell did you keep yourself from making some inappropriate comment when you saw that for the first time? My eyes would have been as wide as saucers! Huh... I'm really surprised a doc would make that choice-- not only are those really small "elevations" and not visible in 3 contiguous leads, but there is a left bundle which in general will confound evaluation of the ST segment anyways! Did you ever hear back how the cath went? ...Or at least cardiac labs?

Excuse my language but holy shit!!! :shock:

^^ I'm not seeing the STEMI in that one, especially in the setting of LBBB.... Maybe some P and T changes (a dialysis patient, maybe?), but no big MI.. Maybe I'm missing something...? :scratch:

I suppose it makes sense, though if 0.5mg doesn't work, I don't see 1mg making that much of a difference. I think the repeat doses are meant to keep the rate up as the drug metabolizes rather than increase the dosage. ACLS says we can use dopa or an epi drip as well if the atropine really doesn't work. ...Probably an on-line medcon order for most services. Anything to avoid pacing conscious alert people who are only mildly symptomatic, I suppose...

I hate unknown AMS. The differential is pretty much: 1) Neurogenic (seizures, cva, psych) 2) Metabolic (sugar, hyper/hypo 'lytes) 3) Tox (considering what was available for injestion/inhalation/etc) 4. Hemodynamics (cardiac, bleeds, trauma, etc) The H's and T's work as well... Often times besides the obvious (BGL readings, obvious OD signs, history of similar conditions) there is little we can do to isolate the cause of an unknown AMS. As far as prehospital care, I would focus on things that would be important to me: -Seizures? Check for incontinence, history, meds --> be prepared for another seizure -CVA? Check pupils, BP, history --> routine ALS, expedite transport if appropriate -Tox? Consider scene safety, find out what patient had access to. -Psych? Extra hard sternal rub, brush the eyelashes. Find out about history. -Imbalances? 12 lead ECG, routine ALS -Hemodynamics? Treat VS as indicated, consider traumatic history... All in all not much we do besides the real basics. If there was a gag reflex and the providers don't have protocol for sedated intubation or RSI there really isn't much to do besides supportive care. The resources of the ED really shine in cases like these, while at the same time the limitations of EMS are made painfully clear.

Its actually a post-arrest 12 lead, but I think its safe to say that he's having an MI as well haha :shock:

I think this is a terrible idea. Is our field really this procedure-crazy? Separating skills from the providers capable of utilizing them is a horrible plan, and really serves no purpose other than allowing first responders to "play" before the ALS arrives. This would increase chances of infection, complicate the transfer of medical care, and potentially cause harm to patients through emphasis on the wrong treatments. I understand you are a RN, but when you are working as a firefighter you are a first responder, and that is it. On a code you should be providing CPR and ventilations, nothing more. I personally believe that - unless there is a special arrangement like in the hospital - the person responsible for the patient's care should be in charge of when/how/where procedures are done. Performing "advanced" skills prior to fully understanding the patient's condition on the ALS level is inappropriate and potentially dangerous.

Though I may be misunderstanding the duties of this "post," I dont see how EITHER firefighter or EMT are qualified to stand guard and watch for a someone fleeing the police. That is not either of our jobs, and neither agency should have accepted it.

Great topic! I've been thinking about this a lot lately. It is nice to say that we give pain medications "based on presentation only," but in my experience that is nothing more than a nice-sounding phrase. Pain is a subjective thing. Sure we can look at mechanism, look at the injuries, look at the history and our objective evaluations of a patient's pain, but when it comes down to it we do NOT have a reliable way to understand pain that we are not experiencing ourselves. So what do we do? Give the meds to anyone who asks for it? No way. We have to make decisions about these kinds of patients based on information that may not be exactly... "scientific." I don't like it about myself, but I have to agree with others who admitted that they allow race and economic status to play a role in these decisions. When someone is in pain (and ESPECIALLY if they ask for meds), I am always on the alert for drug seeking behavior. I don't feel like this is really part of my job as a medical provider, but the reality of the world is that we need to protect ourselves from those who would use us for the medications we carry. I try to avoid giving meds to drug seekers because it reinforces an addictive behavior that is destructive to both the patient and the EMS system. Though I don't like it, I have to admit that my index of suspicion for drug seeking behavior is higher for those of certain socioeconomic backgrounds. Based on experience I have found that people from certain neighborhoods are more likely than others to overstate pain and seek drugs. Though I have found this behavior in mansions as well as shanties, the truth of the matter is that it occurs more in one group than the other. I don't like this. I've been thinking about it a lot lately and questioning as to whether this is something that should ever come to mind as a provider of medical care. I'm glad this topic was brought up so I can see what others feel about it.

I don't always palpate for the artery before I listen to a blood pressure. It is helpful sometimes, but in general I know about the area that it will be in and the bell of the stethoscope is big enough to assure that I'll be in the vicinity. My advice would be to not get caught up trying to palpate. Work on tuning your ears instead.

We have a protocol for tylenol as well. It is not IV but a PO dropper preparation. We have it for pediatric fevers, but to be honest I don't really consider this to be an "emergency" medicine that is all that necessary.

Yeah man, pretty close. Was it one of those beds with the cranks at the end to raise/lower/sit up/lay back etc? I freaking HATE those things.