12 lead and oxygen

[Kaisu]

f we ever get 12 leads on our rigs, and if we ever convince the ED docs to pay the slightest attention to our interpretations, then I can start to think about doing a 12 lead before O2.

Like many things, what we do is so much based on where we run. I am still dealing with idiots that say a 12 lead on the rig would be a bad thing because then these stupid medics would delay transport to get a 12 lead that would be done at the hospital anyway...

I gotta get the f*** outta here...

[crotchitymedic1986]

You guys are kidding right ? You would withold treatment that could help for a diagnostic test that is worthless in the field ? Let's try this thinking in other situations: You have an arterial bleeder; do you put pressure on the wound or do you wait until you have a blood pressure palpated ? You have a COPD patient with serious respiratory distress (tripod, cyanosis, accessory muscle use), do you put on the O2 and start an IV immediately, or wait until your pulse ox confirms distress ?

[WolfmanHarris]

You would withold treatment that could help for a diagnostic test that is worthless in the field ?

Care to explain this? Specifically the bolded section.

[VentMedic]

If their SPO2 is good ~ 98% RA the two litres on an NC we'll give probably has FA effect.

SpO2?

What is the relationship between the SVO2, DO2, and VO2?

You have to be thinking about the pathophysiology behind various disease processes and what factors pain influences. SpO2 is just one number. If there is any possibility that cardiac output will be affected, so will the SvO2 and tissue oxygenation. The SpO2 will not always reflect that. Even if you do not have advanced monitoring capabilities you can still get a good idea about what direction your patient's cardiac output might take be it high or low. You also may have the consequences of tissue hypoxia even if the SpO2 remains high.

Multitask and do both since you should have a partner around or a dozen fire medics in some areas.

[crotchitymedic1986]

Care to explain this? Specifically the bolded section.

Yes, in my humble opinion, the 12Lead in the field is useless unless you carry thrombolytics on your truck, and use them. My rationale is that it rarely changes out-of-hospital or in-hospital treatment, WHY:

1. 99% of patients will be treated the same way in the field regardless of what the 12 Lead shows; do you withold NTG, O2, and MS because of a negative 12 Lead ? NO Do you not transport due to a negative 12 Lead ? NO Does it change where you transport the patient to ? In rare circumstances yes, but I hope that you do not transport chest pain patients to hospitals that do not have cath labs, regardless of what the 12 lead says.

2. As we all know, 12 Lead changes may not occur until many hours after the onset of symptoms, so a negative 12lead 20 minutes after the onset of symptoms means nothing.

3. Positive 12-Leads in the field do not speed-up door to needle times or door to cath lab times in most facilities. Most facilities already have time parameters for these patients regardless of how they arrive. The hospital will still redo the 12-lead, and will not call the Cath Lab team until the hospital 12-Lead has been read.

4. But rather than me blather on and on, please provide any scientific proof that you have that shows that 12-Leads done in the field increase survivability or muscle. Who knows, maybe I am wrong, but I doubt it.

5. If you want to invest in something useful, ditch your 12leads and buy Istat machines so that you can do a cardiac lab panel on the truck. But even those levels may not rise right away.

[Jwade]

Yes, in my humble opinion, the 12Lead in the field is useless unless you carry thrombolytics on your truck, and use them. My rationale is that it rarely changes out-of-hospital or in-hospital treatment, WHY:

1. 99% of patients will be treated the same way in the field regardless of what the 12 Lead shows; do you withold NTG, O2, and MS because of a negative 12 Lead ? NO Do you not transport due to a negative 12 Lead ? NO Does it change where you transport the patient to ? In rare circumstances yes, but I hope that you do not transport chest pain patients to hospitals that do not have cath labs, regardless of what the 12 lead says.

2. As we all know, 12 Lead changes may not occur until many hours after the onset of symptoms, so a negative 12lead 20 minutes after the onset of symptoms means nothing.

3. Positive 12-Leads in the field do not speed-up door to needle times or door to cath lab times in most facilities. Most facilities already have time parameters for these patients regardless of how they arrive. The hospital will still redo the 12-lead, and will not call the Cath Lab team until the hospital 12-Lead has been read.

4. But rather than me blather on and on, please provide any scientific proof that you have that shows that 12-Leads done in the field increase survivability or muscle. Who knows, maybe I am wrong, but I doubt it.

5. If you want to invest in something useful, ditch your 12leads and buy Istat machines so that you can do a cardiac lab panel on the truck. But even those levels may not rise right away.

If I may be so bold! Actually, Many places are now carrying retevase on the trucks, so YES we do use them and have been for many years!!!!

I don't know what part of BFE you practice in, but almost ALL of the cath labs that are worth a damn will mobilize the team based on field interpretation of the 12 or 15 lead EKG, including both ground and air! Sorry to burst your bubble, but sounds like your neck of the woods is a little behind the times....

Respectfully,

JW

[VentMedic]

If I may be so bold! Actually, Many places are now carrying retevase on the trucks, so YES we do use them and have been for many years!!!!

I don't know what part of BFE you practice in, but almost ALL of the cath labs that are worth a damn will mobilize the team based on field interpretation of the 12 or 15 lead EKG, including both ground and air! Sorry to burst your bubble, but sounds like your neck of the woods is a little behind the times....

Respectfully,

JW

I wouldn't say there are "many" ALS services carrying Retavase. Unfortunately, there are many EMS companies that do not have 12 lead capability and some that do are not able to transmit to the ED. And, not all cath labs will activate unless someone with MD behind their name makes the call. The ED physician or cardiologist on call activates after seeing the 12-lead from the field. These situations are NOT just for BFE. California is full of major cities that do not have 12-lead capability and some 911 agencies must still transport to the nearest facility with a chest pain regardless of clinical findings. There are also cities such as those in Southern CA that probably shouldn't have 12-lead capability as their poor results and cath lab physician frustration with them was made known.

Thrombolytics have been trialed in U.S. EMS even in the 1980s but with cath labs springing up everywhere, some of the cities involved initially did not see a need to continue that protocol. There are a few EMS agencies that do have this protocol but much of the literature is from other countries where EMS is slightly more advanced than the U.S. Of course in the U.S. your flight and specialty teams may be the exception which is what you are most familar with.

[tniuqs]

I agree completely....In the OP original scenario, I would not blast anyone with O2 until 12 lead was done.

If you have a blocked vessel causing injury or ischemia to the heart, then blasting O2 will not do much....

(And please spare me the lecture on diffusing into the plasma again).

The ENTIRE GOAL of treating, pre-hospital chest pain is to decrease MVo2 demand.

It has been my experience most people who are truly having a cardiac event will get more anxious( read: claustrophobic) when sticking a NRB at 15l on them right off the bat....I will usually start with a NC at 4-6 and titrate along with other meds to relieve MVo2 demand.

Dear Kevkie:

Oh and a link to Wellens Syndrome, I have searched the literature but no where can I find that early delivery of 02 is detrimental.

http://emedicine.medscape.com/article/1512230-overview

Dear crotchitymedic1986:

5. If you want to invest in something useful, ditch your 12leads and buy Istat machines so that you can do a cardiac lab panel on the truck. But even those levels may not rise right away.

Firstly I would love to have an I Stat ... unfortunately for every ABG the cassette per use is rather pricey, let alone cardiac panel "add ons"

I would not be quite as extreme but there are very reliable bedside Troponin kits are available try TNT diagnostics, a very cost effective alternative and elevated Trop levels an excellent piece of kit if carrying any thromolytics, heck even if you don't have a 12 Lead.

cheers

Edited December 1, 2009 by tniuqs

[Jwade]

I wouldn't say there are "many" ALS services carrying Retavase. Unfortunately, there are many EMS companies that do not have 12 lead capability and some that do are not able to transmit to the ED. And, not all cath labs will activate unless someone with MD behind their name makes the call. The ED physician or cardiologist on call activates after seeing the 12-lead from the field. These situations are NOT just for BFE. California is full of major cities that do not have 12-lead capability and some 911 agencies must still transport to the nearest facility with a chest pain regardless of clinical findings. There are also cities such as those in Southern CA that probably shouldn't have 12-lead capability as their poor results and cath lab physician frustration with them was made known.

Thrombolytics have been trialed in U.S. EMS even in the 1980s but with cath labs springing up everywhere, some of the cities involved initially did not see a need to continue that protocol. There are a few EMS agencies that do have this protocol but much of the literature is from other countries where EMS is slightly more advanced than the U.S. Of course in the U.S. your flight and specialty teams may be the exception which is what you are most familar with.

VENT,

I am going to disagree with you, I am JUST as familiar with ground EMS as I am with FLIGHT, I actually did work the ground in DETROIT no less.......Does NOT get any worse than detroit, trust me....

I have many friends who work ground all over the country, and the majority have protocols for retevase, and actually do use it.......I never said ALL cath labs would activate, I said, the ones with which I have experience both in Michigan, Arizona, Utah, Colorado, Oregon, Ohio, New Hampshire,etc....... will >90% of the time activate based on field 12 lead. I have personally delivered MANY patients both ground and air straight to the cath lab and bypassed the ER.....

You keep using California and Florida as your primary ammunition in all of your comments, You could NOT pick any two worse states for crappy EMS services and education standards.

Please remember, I also spent 11 years in Europe, so I am EXTREMELY familiar with what goes on all over the world...

Respectfully,

JW

[1EMT-P]

I can't believe that we are having this discussion, a patient c/o of chest pain should receive an immediate assessment along with cardiac monitoring, oxygen, aspirin unless contraindicated, a 12 lead ECG, IV access, labs should be drawn if you are allowed to do so & a pre-hospital checklist/screening should be completed. You might also want to consider giving nitro & pain medication like morphine prn as tolerated!