paramedicmike Posted July 8, 2017 Posted July 8, 2017 What's a lactate going to tell you? Is there a sepsis concern here? Doesn't sound like it. Sure, if you have point of care testing capabilities you could get a baseline so long as it's not going to take away from getting this guy to a center with interventional neuro capabilities. He does not need the community hospital unless it's on the way and the helicopter can meet you there. Otherwise, to be cliche, time is brain. Twenty five minute ETA on the helicopter (birds don't carry people) plus a ten minute scene time plus a 15-20 minute flight time means 50-55 minute ETA to the stroke center versus 45 minutes by ground. Why are you still on scene? Drive.
FireEMT2009 Posted July 8, 2017 Author Posted July 8, 2017 (edited) 2 hours ago, paramatt_ said: A bit late, but just a couple things to add.. Id also be heading to the nearest facility with neuro. Btw; have we had a good look at his head..ie any recent trauma/falls/head strike? Probably not going to change our management but the reviewing facility would want to know potential med vs trauma aetiology. No head trauma or recent falls. Il. As air vs ground, unless he's going to get RSI'd, he poses too much of a risk of dropping his bundle mid flight. Would definitely want an extra pair of hands in the back during the transport He is alert other than his difficulty recalling certain information, and is fully able to handle his own airway. 1 hour ago, paramedicmike said: What's a lactate going to tell you? Is there a sepsis concern here? Doesn't sound like it. Sure, if you have point of care testing capabilities you could get a baseline so long as it's not going to take away from getting this guy to a center with interventional neuro capabilities. He does not need the community hospital unless it's on the way and the helicopter can meet you there. Lactate levels that are higher than normal (above 2.0) not only indicates infection/sepsis, but can also point towards bleeding in the body. Our lactate testing only takes a minute to complete and can be done with just a tiny bit of blood and can be easily done especially during the elongated transport. Otherwise, to be cliche, time is brain. Twenty five minute ETA on the helicopter (birds don't carry people) plus a ten minute scene time plus a 15-20 minute flight time means 50-55 minute ETA to the stroke center versus 45 minutes by ground. Why are you still on scene? Drive. Absolutely! I couldn't agree more! Edited July 8, 2017 by FireEMT2009
paramedicmike Posted July 8, 2017 Posted July 8, 2017 8 hours ago, FireEMT2009 said: Lactate levels that are higher than normal (above 2.0) not only indicates infection/sepsis, but can also point towards bleeding in the body. Incorrect. Lactate is a marker for cellular hypoxia. It does not point towards bleeding in the body. Rather, it points towards a lack of perfusion which can be caused by a variety of factors. So fine. You check a lactate and it's elevated. Then what? Is this ischemic? Is this hemorrhagic? You still don't know. Will it impact your care? Not likely. Is it entirely bad? There is some evidence to suggest that lactate can be neuroprotective in a stroke. Here's some reading for you. Here's some more. Ok. So you check it and it's elevated. Then what? Treat your patient not the number. If you have treatment guidelines that address lactate levels in CVA then please share. Otherwise, outside of suspected sepsis what benefit is offered by knowing? Is there a purpose to doing it or is it just cool to roll in and have a lactate value?
FireEMT2009 Posted July 10, 2017 Author Posted July 10, 2017 (edited) On 7/8/2017 at 7:55 AM, paramedicmike said: Incorrect. Lactate is a marker for cellular hypoxia. It does not point towards bleeding in the body. Rather, it points towards a lack of perfusion which can be caused by a variety of factors. So fine. You check a lactate and it's elevated. Then what? Is this ischemic? Is this hemorrhagic? You still don't know. Will it impact your care? Not likely. Is it entirely bad? There is some evidence to suggest that lactate can be neuroprotective in a stroke. Here's some reading for you. Here's some more. Ok. So you check it and it's elevated. Then what? Treat your patient not the number. If you have treatment guidelines that address lactate levels in CVA then please share. Otherwise, outside of suspected sepsis what benefit is offered by knowing? Is there a purpose to doing it or is it just cool to roll in and have a lactate value? I agree, and I apologize for my delayed response. Lactate levels are there to show hypo-perfusion, I was using it in this scenario as a way to detect the hypo-perfusion of the brain in this case since this case deals with a possible head bleed or CVA. Even though we all can tell this is some sort of neurological impact, it may not be exactly clear whether or not this is a CVA, TIA, infection, etc.I understand that I "mis-typed" my response by oversimplifying it to a point that it became muddled and incorrect, and for that I apologize. I don't glamorize lactate as just a cool tool, but as a diagnostic tool to build,and strengthen my differential diagnosis. I know field lactates are very sparse in who has them or doesn't have them, therefore was just giving a way to see if anyone, A. used them, and B. would want the information there if they had access to it. I am all about treating my patient not my machines. Edited July 10, 2017 by FireEMT2009
paramedicmike Posted July 10, 2017 Posted July 10, 2017 2 hours ago, FireEMT2009 said: Even though we all can tell this is some sort of neurological impact, it may not be exactly clear whether or not this is a CVA, TIA, infection, etc. Say what? Where's your physical exam? The only way you're going to have any idea as far as forming a differential diagnosis is with a good history and thorough physical exam: something we in EMS aren't always good at. (Before you think I'm dinging you I'll say upright that I'm not. We're all human. We all do it to some extent.) Focal neuro deficits? Ok... wide variety of neuro considerations to be made. Do they resolve in a given period of time? Consider TIA. Progressive or persistent? Consider CVA. Fever or other considerations for infection (e.g. urinary symptoms, cough among others)? Sepsis. History or exam findings that point you down another road? Consider an alternate diagnosis. Several services with which I'm familiar use lactate POC testing for suspected sepsis but not for anything else. Locally, prehospital lactate POC in suspected sepsis has increased our recognition of sepsis, decreased door to antibiotic times and improved our overall sepsis outcomes. From what's been posted this guy needs a center capable of handling an acute CVA. He needs safe, rapid transport. He needs continuous monitoring. He needs serial neuro checks. He needs a head CT. He needs a neuro consult. Intervention will depend on what's found after work up with imaging. So what was the outcome of this guy? It's an interesting case with what sounds like a monitored progression of his symptoms.
FireEMT2009 Posted July 10, 2017 Author Posted July 10, 2017 12 minutes ago, paramedicmike said: Say what? Where's your physical exam? The only way you're going to have any idea as far as forming a differential diagnosis is with a good history and thorough physical exam: something we in EMS aren't always good at. (Before you think I'm dinging you I'll say upright that I'm not. We're all human. We all do it to some extent.) Focal neuro deficits? Ok... wide variety of neuro considerations to be made. Do they resolve in a given period of time? Consider TIA. Progressive or persistent? Consider CVA. Fever or other considerations for infection (e.g. urinary symptoms, cough among others)? Sepsis. History or exam findings that point you down another road? Consider an alternate diagnosis. Several services with which I'm familiar use lactate POC testing for suspected sepsis but not for anything else. Locally, prehospital lactate POC in suspected sepsis has increased our recognition of sepsis, decreased door to antibiotic times and improved our overall sepsis outcomes. From what's been posted this guy needs a center capable of handling an acute CVA. He needs safe, rapid transport. He needs continuous monitoring. He needs serial neuro checks. He needs a head CT. He needs a neuro consult. Intervention will depend on what's found after work up with imaging. So what was the outcome of this guy? It's an interesting case with what sounds like a monitored progression of his symptoms. I don't think you are dinging me at all, criticism and discussion makes us better as providers. I don't believe I gave enough information on the assessment that was actually performed. There was no fever in this case, nor any resolution in his symptoms. They actually evolved and worsened over the transport. As far as I know it was listed as a CVA although I know there was no head bleed, which was what I was suspecting throughout the transport.. This was an interesting case, but sometimes, as we all find out, it may not overly work well in scenario forums especially since it is all dependent on if I give the correct information in the right places.
Just Plain Ruff Posted July 10, 2017 Posted July 10, 2017 his was an interesting case, but sometimes, as we all find out, it may not overly work well in scenario forums especially since it is all dependent on if I give the correct information in the right places. Plus it helps if more people participate than just a couple of people.
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