Three little questions

[Brandon Oto]

I've bumped into a few little oddities or inconsistencies recently, and I figured I'd roll them all together and ask for input on them. Interested in any thoughts.

1. I was originally taught that during a field birth, you suction the neonate's mouth and nose as soon as the head becomes available. This is to prevent aspiration of meconium once the little bugger starts breathing. However, I've been flipping through the 2005 AHA recommendations and I note that they actually do not recommend this practice, called "intrapartum suctioning"; according to their review of the literature it shows no benefit to either decreased infant mortality or decreased aspiration. Some poking around on my own seems to confirm this. What do you guys think? My service still stocks little bulb syringes for exactly this. I'm not 100% clear, however, on whether the AHA et al. are contrasting intrapartum suctioning with NO suctioning, or with suctioning after completion of the second stage of labor.

2. CPR and PALS guidelines recommend chest compressions on an infant with signs of inadequate perfusion and a HR below 60. This is because, well -- that's not good enough. My question -- why isn't this an option for profound, symptomatic bradycardia in ADULTS? You medics can go to town with pacing or meds, but if you're BLS and presented with a patient showing shock and a very slow pulse (I'm thinking, for instance, a drug overdose or a hypothermia case), why can't we use the above logic to begin compressions and increase circulation manually? I've never seen this recommended but it's not clear to me why it wouldn't work, except maybe minor paranoia about commotio cordis.

3. Just what on earth is Cushing's triad really supposed to be? I thought I knew, but I've seen three versions: hypertension + bradycardia + irregular respirations; hypertension + bradycardia + widening pulse pressure; widening pulse pressure + bradycardia + irregular respirations. The second is the one I knew but apparently everyone has their own version. Try a quick Google -- it's kinda funny. Thoughts?

[Jwade]

I've bumped into a few little oddities or inconsistencies recently, and I figured I'd roll them all together and ask for input on them. Interested in any thoughts.

1. I was originally taught that during a field birth, you suction the neonate's mouth and nose as soon as the head becomes available. This is to prevent aspiration of meconium once the little bugger starts breathing. However, I've been flipping through the 2005 AHA recommendations and I note that they actually do not recommend this practice, called "intrapartum suctioning"; according to their review of the literature it shows no benefit to either decreased infant mortality or decreased aspiration. Some poking around on my own seems to confirm this. What do you guys think? My service still stocks little bulb syringes for exactly this. I'm not 100% clear, however, on whether the AHA et al. are contrasting intrapartum suctioning with NO suctioning, or with suctioning after completion of the second stage of labor.

2. CPR and PALS guidelines recommend chest compressions on an infant with signs of inadequate perfusion and a HR below 60. This is because, well -- that's not good enough. My question -- why isn't this an option for profound, symptomatic bradycardia in ADULTS? You medics can go to town with pacing or meds, but if you're BLS and presented with a patient showing shock and a very slow pulse (I'm thinking, for instance, a drug overdose or a hypothermia case), why can't we use the above logic to begin compressions and increase circulation manually? I've never seen this recommended but it's not clear to me why it wouldn't work, except maybe minor paranoia about commotio cordis.

3. Just what on earth is Cushing's triad really supposed to be? I thought I knew, but I've seen three versions: hypertension + bradycardia + irregular respirations; hypertension + bradycardia + widening pulse pressure; widening pulse pressure + bradycardia + irregular respirations. The second is the one I knew but apparently everyone has their own version. Try a quick Google -- it's kinda funny. Thoughts?

Brandon,

Hopefully, I can clear some of this up for you.

1. When delivering a baby, NRP recommends the oropharynx to be suctioned first, followed by the nares. The theory behind this, stimulation of the nares may cause the infant to gasp and aspirate secretions which are present in the oropharynx, ( Meconium being one of them). Also, remember not to suction too vigorously, no more than 100mm HG of negative pressure to avoid common injuries. Also, too much rigorous suctioning could overstimulate the vagus nerve and thus produce profound bradycardia..

2. Adult SYMPTOMATIC Bradycardia can be treated with the following options. Atropine ( unless 3 degree AV block), Pacing, and finally CPR.......SO, YES, you can do CPR on an adult in this situation....

3. Cushing's Triad is when you have an increase in ICP ( Inter-cranial Pressure, ) which causes compression of the cerebral blood vessels causing ischemia to the brain. This may be represented by Increase in Blood Pressure / Decrease in HR / Decrease in Respiratory Drive. This is a real event that you can easily witness in the field, as I have seen it many times both in the field and during my days First Assisting in the Operating Room...

Hope this helps.

Respectfully,

JW

[Brandon Oto]

I guess this has been moved into the Students forum. I have to admit that I find that vaguely offensive, since I'm not a student (except in the loose sense that we're all students...), and since in my opinion these are "questions" not because I haven't flipped to the right book but because the books don't seem to agree.

Maybe these are all obvious issues to whoever moved this, but if so I'd appreciate them sharing with the rest of us, because they are non-obvious to me; and yes, I am a working EMT.

[tniuqs]

Brandon,

<snip>

Respectfully,

JW

+ 5 on the dust devil scale.

1. The theory behind this, stimulation of the nares may cause the infant to gasp and aspirate secretions which are present in the oropharynx.

Just one addition the neonatal is an obligatory nasal breather agreed very vagal responses if suctioned excessively but well this thing we called birth process has been quite successful without any suction intervention before EMS. Most cephalic presentations, well as my pilots used to say (Gravity Sucks)the hang them by the feet thing its a darn good way to hang on to those slippery slimy things too, just a little WTF where is the suction

If meconium is detected this is the time to actually intubate while body of child has not delivered and use a mec aspirator and remove the ETT while sucton applied, that said far easier in a proper birthing chair. As if that is likely where we work ... more like a taxi and a damn door that will NOT open up wide enough ... oh hose monkeys go get the Hurst tool fired up would you ? j/k.

to the OP with good queries like these ... you are on your way to becoming a Paramedic

cheers

Edited November 5, 2009 by tniuqs

[Brandon Oto]

On the suctioning point, here was that bit of the AHA recs:

"Aspiration of meconium before delivery, during birth, or during resuscitation can cause severe aspiration pneumonia. One obstetrical technique to try to decrease aspiration has been to suction meconium from the infant’s airway after delivery of the head but before delivery of the shoulders (intrapartum suctioning). Although some studies suggested that intrapartum suctioning might be effective for decreasing the risk of aspiration syndrome, subsequent evidence from a large multicenter randomized trial did not show such an effect. Therefore, current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid (Class I)." (http://circ.ahajournals.org/cgi/content/full/112/24_suppl/IV-188)

The main study cited in support notes:

"No significant difference between treatment groups was seen in the incidence of MAS, need for mechanical ventilation for MAS, or in the duration of ventilation, oxygen treatment, and hospital care. INTERPRETATION: Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation infants born through MSAF does not prevent MAS. Consideration should be given to revision of present recommendations." (http://www.ncbi.nlm.nih.gov/pubmed/15313360?dopt=Abstract)

This was nearly five years ago, so I don't know if there has been any more recent data. Nevertheless, my EMT text still teaches the suctioning and I believe it's required in most state testing. And my protocols state:

"10. Suction mouth, then nose of the infant as soon as possible." (pg. 82, http://www.mass.gov/Eeohhs2/docs/dph/emergency_services/treatment_protocols_704.pdf)

[tniuqs]

Thanks for the link, have not read it all but first time I believe I have seen a study out of Argentina .

cheers

[scubanurse]

I guess this has been moved into the Students forum. I have to admit that I find that vaguely offensive, since I'm not a student (except in the loose sense that we're all students...), and since in my opinion these are "questions" not because I haven't flipped to the right book but because the books don't seem to agree.

Maybe these are all obvious issues to whoever moved this, but if so I'd appreciate them sharing with the rest of us, because they are non-obvious to me; and yes, I am a working EMT.

It was probably moved because it involved education and the disagreeableness of educational resources. I really wouldn't read too much into it or take it offensively...but if that's how you want to take it go for it.

[DwayneEMTP]

I guess this has been moved into the Students forum. I have to admit that I find that vaguely offensive, since I'm not a student (except in the loose sense that we're all students...), and since in my opinion these are "questions" not because I haven't flipped to the right book but because the books don't seem to agree.

Maybe these are all obvious issues to whoever moved this, but if so I'd appreciate them sharing with the rest of us, because they are non-obvious to me; and yes, I am a working EMT.

No worries brother. I've had posts moved and deleted for reasons that make no sense to me. Not saying there was no logic, I just couldn't reach it.

Don't let it worry you. It seems that the post gremlins get fired up every now and then, but it will pass.

Good questions, good post, let's just keep chugging along on a positive track, OK?

Dwayne

[Brandon Oto]

Forget it. Let's just work on shining a little light on a confusing world.

John, is CPR for brady an ACLS thing? I've never run into hide nor hair of it on the basic side and I suspect numerous layers of people above me would have kittens if I pulled that one on scene.

[Jwade]

Forget it. Let's just work on shining a little light on a confusing world.

John, is CPR for brady an ACLS thing? I've never run into hide nor hair of it on the basic side and I suspect numerous layers of people above me would have kittens if I pulled that one on scene.

Brandon,

YES, Pretty much an ACLS thing, although, when i teach BLS to healthcare providers, I will go over it as well.. I am an AHA BLS/ACLS/PALS instructor, and I find there are quite a few ambiguous areas unfortunately.

ACLS standard for symptomatic brady is , atropine .5-1mg IVP ( Unless a 3 degree AV block exists), Transcutaneous Pacing, and CPR if none of that works or no pacer available. Your only other alternative is to sit and watch them progress from bradycardia to asystole by doing nothing. Take your pick?

PS. AND you must make sure you have ruled out any reversible causes. 6h's and 5t's

Respectfully,

JW

Edited November 5, 2009 by Jwade