ALS or BLS

[Ace844]

Cryoprecipitate is a plasma derivative rich in vWF, fibrinogen, and fibronectin that has traditionally been used in the treatment of hemophilia A, von Willebrand disease, hypofibrinogenemia, and dysfibrinogenemia. Cryoprecipitate corrects prolonged bleeding in uremic patients within 4 to 12 hours, and the effect lasts 24 to 36 hours.[237] The mechanism of action of cryoprecipitate is not known. A small rise in platelet levels of fibrinogen and vWF-related proteins were the only changes noted after cryoprecipitate infusion. Different preparations of cryoprecipitate, however, had different effects on bleeding time.[345] The poor reproducibility of results and the risk of disease transmission prompted the search for alternatives to cryoprecipitate.

Desmopressin (1-deamino-8-D-arginine-vasopressin)—a synthetic derivative of antidiuretic hormone—induces the release of autologous vWF from storage sites.[346] In a randomized, double-blind, crossover trial, desmopressin given intravenously at a dose of 0.3 mg/kg body weight in 50 mL of physiologic saline over a period of 30 minutes temporarily corrected the prolonged bleeding time in patients with chronic renal failure.[218] The shortening of bleeding time was significant 1 hour after the end of the infusion, and the effect lasted 6 to 8 hours. Desmopressin loses efficacy with repeated administration. [347] Desmopressin also can be given by the intranasal route,[348] [349] which is well tolerated and quite safe. At 10 to 20 times the intravenous dose (3 mg/kg) intranasal desmopressin shortens the bleeding time[348] [349] and decreases clinical bleeding. Desmopressin has also been given subcutaneously,[350] with the dose the same as that used for intravenous administration. Peak responses are achieved after a 30- to 90-minute delay when the subcutaneous route is employed. Adverse effects include facial flushing, mild transient headache, nausea, abdominal cramps, and mild tachycardia. Protein C anticoagulant activity decreases after desmopressin infusion.[351] [352] In one case report, an elderly uremic patient with atherosclerosis suffered a stroke immediately after desmopressin infusion.[353] Nonetheless, desmopressin is useful in the treatment of bleeding, and in the prevention of bleeding during surgery or invasive procedures.

The anecdotal observation of diminished gastrointestinal bleeding in uremic patients treated with conjugated estrogens, and the improved hemostasis in von Willebrand disease during pregnancy, led to investigations of the effect of estrogens on bleeding in uremia.[354] [355] [356] One oral dose of 25 mg of conjugated estrogen normalizes the bleeding time for 3 to 10 days, with no apparent ill effects.[354] A controlled study showed that conjugated estrogens, given intravenously at a cumulative dose of 3 mg/kg divided over 5 consecutive days, produced a long-lasting reduction in the bleeding time in uremic patients. At least 0.6 mg/kg of estrogen was needed to reduce the bleeding time,[356] and four or five infusions spaced 24 hours apart were needed to reduce the bleeding time by at least 50%. The effect of estrogens on bleeding time in an animal model of chronic uremia was completely reversed by the NO precursor L-arginine, [201] suggesting that the effect of estrogens might be mediated by changes in NO synthesis. Thus, estrogens may be a reasonable alternative to cryoprecipitate or desmopressin in the treatment of uremic bleeding, especially when a long-lasting effect is required.

[TechMedic05]

What's the transport time? Has the bleeding been stopped prior to arival or is she actively bleeding? What are the capabilities of the on scene crew, if BLS will waiting for ALS be too long?

Since starting an IV on this patient opens the chance of another bleeding site, why??If as you say, lotsa heparin. Plus What fluids and why?? What will a crystalloid accomplish and if too much, hey she has kidney problems, right??

A good BLS crew could transport this pt. O2 supine, monitor( I don't mean EKG or any other machine) the old fashioned clinical skill of monitoring a patient with your eyes, ears, nose. Cave man stuff

First off, 250 NS will probably do a rather decent job at improving her orthostatic state. Is it permanent? No. Definitive? No. But will it help her out for now? Absolutely.

As far as starting an IV, why are you worried about starting another bleeding site? And besides, just because a patient has heparin [be it overdose, or appropriate] - that doesn't mean that bleeding is instantly non-controllable.

I understand not waiting on scene - that's managing a good dual response or intercept style EMS system, kudos for the thoughts!

We apparently have a slightly hypovolemic patient in early signs of shock. Renal failure aside, how sick does a patient need to be to warrant ALS treatment? Only in very few instances should travel time to the ED be an issue, as well. if they're sick, work them up. Doesn't matter how long or short of a transport, right?

[redbkirk2001]

Alright.......I'm going to say ALS, because the systolic pressure dropped more than 15 points [yes it is still above 100 and she would obviously be lying down in the back] from lying down in the chair to standing up. The "lightheadedness" could be a result of the dialysis, but who knows. With the heparin onboard she'll have a longer clotting time(yea I know DUH!!). Well.......that's all from me right now.

[Ace844]

Alright.......I'm going to say ALS, because the systolic pressure dropped more than 15 points [yes it is still above 100 and she would obviously be lying down in the back] from lying down in the chair to standing up. The "lightheadedness" could be a result of the dialysis, but who knows. With the heparin onboard she'll have a longer clotting time(yea I know DUH!!). Well.......that's all from me right now.

If you read the preceeding posts you can also even learn and come up with more than that!!

Out Here,

ACE844

[PRPGfirerescuetech]

Alot of good posts everyone. This call did go BLS, my partners reasoning being a "normotensive" pressure (regardless of the change from baseline. He was wrong, and I knew it, but i've never made it a practice to kick calls back to the ALS provider. Simply stated, if you boot it to me, its your mistake. Thats why we do QA. He'll learn. I did the oxygen thing, treated for shock and got the bleeding stopped with a pressure dressing.

My point was simple. Theres alot of ways this could have gone, and sometimes we can disagree. Did this call go ok BLS? sure. Could she have crashed out? Certainly. Theres always a varied opinion, because ALs is an ART, not a science. If it was a defined science, would we really be here?

As long as we are doing the best we can with the clinical indicators we have, in the best interest of the patient, we've done our job, and we've done it well.

[Ace844]

Alot of good posts everyone. This call did go BLS, my partners reasoning being a "normotensive" pressure (regardless of the change from baseline. He was wrong, and I knew it, but i've never made it a practice to kick calls back to the ALS provider. Simply stated, if you boot it to me, its your mistake. Thats why we do QA. He'll learn. I did the oxygen thing, treated for shock and got the bleeding stopped with a pressure dressing.

My point was simple. Theres alot of ways this could have gone, and sometimes we can disagree. Did this call go ok BLS? sure. Could she have crashed out? Certainly. Theres always a varied opinion, because ALs is an ART, not a science. If it was a defined science, would we really be here?

As long as we are doing the best we can with the clinical indicators we have, in the best interest of the patient, we've done our job, and we've done it well.

"PRPG,"

Don't you think that perhaps the call went as well as it did BLS was BECAUSE of who the BLS clinician was on this call? Do you think the outcome may have been alittle worse if it had been another BLS clinician?

Out here,

ACE844

[zippyRN]

Not quite sure exactly what you are asking. Are you asking if a BLS unit on scene should call for ALS?

Are you asking if the patient requires ALS care?

Are you asking if it should have been dispatched as ALS?

No, yes, and yes.

i'm with dust here- unless the wait for the ALS unit is 'worth it' ( very prolonged transport time with a short resonse time for ALS)

asa riht pondian i find it odd that people consider a basic / para or even an Int/ Para crew 'limited' in terms of ALS - given the UK default crew on NHS vehicles is tech/ para

[PRPGfirerescuetech]

i'm with dust here- unless the wait for the ALS unit is 'worth it' ( very prolonged transport time with a short resonse time for ALS)

asa riht pondian i find it odd that people consider a basic / para or even an Int/ Para crew 'limited' in terms of ALS - given the UK default crew on NHS vehicles is tech/ para

There no waitfor ALS...dust missed the thread and its point.

Limited MICU comes from the principal that MICU should contain 2 ALS providers, and nothing less. Anything less is thuis limited.