# Arrest



## Smash (Oct 28, 2009)

57 year old male.  History of asthma, no known allergies, takes albuterol reliever.  

Ambulance called by family for shortness of breath.  First crew (ILS) arrive to find patient severely short of breath, speaking words only with great difficlty, very poor air entry globally, no wheeze on auscultation and a prolonged expiratory phase of the respiratory cycle.  Patient was administered albuterol and ipratropium via updraft, IV access gained and loaded to rendezvous with ALS.

En-route to rendezvous pt deteriorates, becomes catatonic, respiratory effort decreases.  IM epinephrine is administered (2 x 300mcg), but pt respiratory arrests, then cardiac arrests.

You arrive to find pt in brady-asystolic arrest (PEA on monitor, rate of 10) with CPR being performed, Oropharyngeal airway in situ and being ventilated with difficulty.

Hospital is 40 minutes + transport time, HEMS is not available.

What do you do and why?


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## mycrofft (Oct 28, 2009)

*Two tweaks*

Catatonia is a psychological/psychiatric diagnosis.
You mean unresponsive or obtunded? (Funny how much value we put on whether the eyelids are oen or closed). Other wise, nice scenario.

What were VS's? EKG was needed too. Brady in response to those drugs means cardiac. We stopped giving inmate Alupent because they would kill them selves trying to self-tx a cardiac insufficiency with Alupent; literally, a couple had their MDI's removed from their dead fingers.

In my experience, when the words aren't coming, you better be going, _mas alles_! Like battle signs and raccoon eyes, not an early finding (unless there is an upper airway embarassment or other laryngeal challenge or insult).


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## Smash (Oct 28, 2009)

Catatonic used in this context where I work relates to the degree of unresponsiveness although not necessarily of a psychological cause.  Obtunded.  Eyes open, not-responding, "thousand yard stare", GCS three but holding posture and maitaining own airway.

Anyway, he's arrested when you arrive.  Brady-asystolic, wide complexes with rate of ~10 on monitor, no output, CPR in progress.  Prior to that, tachycardic (sinus tach) and hypertensive (BP 210/110) becoming hypotensive and progressively bradycardic following respiratory arrest until cardiac arrest about 5 minutes prior to your arrival.


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## MrBrown (Oct 28, 2009)

IV adrenaline; .5mg IVP and hang a drip of 1mg in 1 litre KVO

Would consider a more advanced airway; gaining a seal with an LMA may be difficult given the very high airway pressure.  If possible, intubate the patient but either way ventilate at 6 a minute to avoid dynamic hyperinflation which I fear my have already occured.

Some corticosteriods and magnesium sulfate would be nice right about now.


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## wolfwyndd (Oct 28, 2009)

At this point it sounds like the asthma is a red herring.  Breathing treatment had no effect and (generally) if it's asthma related there's plenty of wheezing going on.  

Since we are on the topic of breath sounds in this SOB patient, what kind of breath sounds are there?  Any?  Any medical history from family, like COPD or emphysema?  It SOUNDS as if this patient has an airway issue that needs to be resolved.


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## mycrofft (Oct 28, 2009)

*All right! Keep it rolling.*

Other meds? 

Asthma may not be THE cause which kicked the pins out from under, but it is/will be a very important dx and tx factor, as well as any remedies taken by the pt before he went down.


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## taporsnap44 (Oct 28, 2009)

Is JVD present? 
Are lung sounds absent on either side? 
Any subcutaneous air around the neck or chest?
Any trachea deviation?
Also how is the chest during compressions? Is it really rigid?

For some reason I am thinking of a possible Tension Pneumothorax.


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## Simusid (Oct 28, 2009)

I'm only a basic, and a new one at that but I'm going to throw out my very first thought and that is pulmonary embolism.


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## usalsfyre (Oct 28, 2009)

Secure an advanced airway (preferably ETT), administer continuous nebs via in-line neb. Assess BBS and chest rise for possible pneumothorax. Does the chest look distended like auto-PEEP is a problem? A manometer would also be a great help here. Greatly diminished breath sounds and prolonged expiratory phase initially are sugestive of RAD, but try to assess for other airway/breathing issues that may have popped up. 

Also, pace the agonal rhytm to see if you can get a response, and continue ACLS algorhythm. Fluid bolus as this pt is very likely to be hypovolemic. This may be a case of irreversible air trapping and nothing you do will help. Consider (carefully and fully) bicarb to reduce acidosis caused by extended CO2 retenetion...


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## Smash (Oct 28, 2009)

Alright, usalfyre is continuing to treat according to ACLS arrest algorhythm which is a good start.  Size 9 ETT passed on first attempt, secured:  EtCO2 180mmHg, SpO2 90% and he's difficult to ventilate.  Epi boluses given, no effect on rhythm  Atropine given, no effect on rhythm.  He does become slightly easier to bag.

Breath sounds:  Slight 'Squeak' when ventilating.  JVD hard to assess due to obesity, no tracheal deviation, no subcutuaneous emphysema, what breath sounds can be heard seem equal. Temperature is 98.9F/37.1C. Blood glucose is normal.

No other history is able to be elicited from the family other than asthma as noted in the first post, and the fact that he was taking his own inhalers during the day.

At least usalfyre is treating the dead guy! 

Anything else?


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## daedalus (Oct 28, 2009)

Notify Dr. G of an incoming patient and wait to see her pathologist report.


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## usalsfyre (Oct 28, 2009)

Smash said:


> Alright, usalfyre is continuing to treat according to ACLS arrest algorhythm which is a good start.  Size 9 ETT passed on first attempt, secured:  EtCO2 180mmHg, SpO2 90% and he's difficult to ventilate.  Epi boluses given, no effect on rhythm  Atropine given, no effect on rhythm.  He does become slightly easier to bag.
> 
> Breath sounds:  Slight 'Squeak' when ventilating.  JVD hard to assess due to obesity, no tracheal deviation, no subcutuaneous emphysema, what breath sounds can be heard seem equal. Temperature is 98.9F/37.1C. Blood glucose is normal.
> 
> ...



Masive air trapping related to refactory bronchospasm causing cardiac output to be so impaired he arrest...This guy is screwed. Could try something like a Res-Q-Pod, but mainly get ready to call the JP.


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## mycrofft (Oct 28, 2009)

*Get his watch.*

Sorry had to stay in character.
Good deal!  We pick up so much during eval simultaneously but to describe and learn  it we have to go linearly.


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## MCGLYNN_EMTP (Oct 28, 2009)

Not sure what you're actualy looking for..I'd treat the immidiate problem here which is the fact that they are in cardiac arrest...Give some epi because the're in PEA...epi also has beta 2 effects which will hopefully loosen up the bronchospasms that this pt. is prob. having....Have to remember that even tho no wheezing is heard on auscultation doesnt mean there isnt bronchospasms....the worst ones sound like clear lung sounds or absent sounds. If Epi doesnt work we can try another albuterol treatment..intubate the patient and give it nebulized through the bag...(kind of hard to rig up but it can be done) go on and give your atropine because the rate is under 60...continue with the algorithm until you change or call the code off... check for allergic reactions too...but again...the epi should help that out.


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## Smash (Oct 28, 2009)

Thought there might be a better turn out than ths. Mind you it's not trauma so maybe it's not that exciting. 

I'll give the "answer" then (how I worked it anyway) 

CPR continued, epi 1mg given with no change. Intubated, size 9 tube, no extensions or so forth to minimize dead space in the circuit. Initial end tidal of 160mmHg, SpO2 of 77%. Ventilated at a rate of about 6/min with a Vt of about 8-10ml/kg. ILS crew continued giving epi and CPR under direction. 

Then the kicker: bilateral chest decompression with pneumocaths- immediate release of copious free air from both sides with an almost immediate ROSC, AF rate of 150, BP 170/100. Occassional agonal respiratory effort, increasing with time, and pt starts to not tolerate the tube so well but GCS remains 3.  

SpO2 increased to 98% EtCO2 trending down to about 100mmHg on arrival at hospital. Chest is still tight, but now has biphasic wheeze and is significantly more compliant. 

So, now we have an output, how would you continue management?  

So, now we have got an output


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## Melclin (Oct 30, 2009)

Aside from some things already mentioned:

AP (our basics)

- Gentle lateral chest pressure and hold the vents for a minute after the loss of cardiac output. 

- Vent with a reduced Vt but increased pressure @ 5-8 a minute. 

-IM adrenaline - 300mcg

MICA (our ALS)

- Bilat decompression - standard MICA treatment for asthmatic arrests with suspected tension pneumo.

- Dexamethasone - 8mg (if they were there before the arrest).

- IV salbutamol 250mcg loading dose, maintenance doses of 125mcg 5 minutely up to a max of 500 mcg OR 15mcg/minute infusion (in severe distress or ROSC). 
- RSI/SFI (again, prob before arrest).


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## WTEngel (Nov 9, 2009)

Don't forget the benefits of chest percussion therapy to release plugging. Be ready for aggressive suctioning in the ET tube, as large plugs of mucous could be released.


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## BLSBoy (Nov 9, 2009)

WTEngel said:


> Don't forget the benefits of chest percussion therapy to release plugging. Be ready for aggressive suctioning in the ET tube, as large plugs of mucous could be released.



How about chest percussion to evaluate for pneumothorax?


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## WTEngel (Nov 9, 2009)

I have found chest percussion only assists in diagnosis of a possible HEMOthorax, as the hyper-resonance heard from the fluid is distinctly different than that of the free air heard from a pneumo.

The idea for chest percussion in this patient is not for diagnosis however, it is to release mucous plugging that prevents the small airways from exchanging gases.


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## VentMedic (Nov 9, 2009)

WTEngel said:


> I have found chest percussion only assists in diagnosis of a possible HEMOthorax, as the hyper-resonance heard from the fluid is distinctly different than that of the free air heard from a pneumo.
> 
> The idea for chest percussion in this patient is not for diagnosis however, it is to release mucous plugging that prevents the small airways from exchanging gases.


 
Fluid will give a dull, "thud" type sound and not the hyperresonant sound found in air filled cavities.  

Chest percussion therapy will be of little use in an acute phase of an asthmatic bronchospasm as the inflammatory response must be addresssed to reduce the narrowing of the airways.   Hydration will also be required to move the mucus.  Rarely will the mucus be in the large airways or can be just "coughed" or "beat" out until after the corticosteriods and fluids have had a chance to work.  

If one believes the patient has bilateral pneumos, use caution with the decompression. You might create more problems than alleviate.  We have had some mistake the decreased breath sounds for pneumos and do several needle sticks into the chest because they did not immediately get a rush of air. What they failed to realize is there may not have been a pneumo until after they started sticking.  As well, a needle decompression will only be effective for a short time and if a code is being worked, a chest tube will have to be inserted to maintain the decompression especially if possitive presssure ventilation is continued.


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## WTEngel (Nov 9, 2009)

I stand corrected.


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## Melclin (Nov 9, 2009)

Smash said:


> Thought there might be a better turn out than ths. Mind you it's not trauma so maybe it's not that exciting.
> 
> I'll give the "answer" then (how I worked it anyway)
> 
> ...



How did you work it like that being an EMT-B, do you mean that you were with a medic who did that, or are you telling little phibs about your level of practice? Student maybe?

Vt seems a little high even for a normal pt. Were you wanting to increase the Vt in an asthmatic arrest? I would have thought you'd back off on the Vt what with dynamic hyperinflation and so on...focussing more on the expiratory phase. With their functional residual capacity through the roof you don't need to be overloading them.


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## VentMedic (Nov 9, 2009)

Melclin said:


> Vt seems a little high even for a normal pt. Were you wanting to increase the Vt in an asthmatic arrest? I would have thought you'd back off on the Vt what with dynamic hyperinflation and so on...focussing more on the expiratory phase. With their functional residual capacity through the roof you don't need to be overloading them.


 
If this patient is hyperinflated with a bronchospasm, the chances of bagging with much to any Vt will be slim to nil without excessive pressure which will of course cause the pneumos. If the patient has bilateral tension pneumos, the chances of ventilating with PIPs of less than 60 cmH2O would not be likely. Of course, even with the pneumos decompresssed the inflammation and bronchospasm will persist and if it is servere enough to cause the patient to code one still won't be able to bag unless they happen to be carrying heliox on their truck.


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## VentMedic (Nov 9, 2009)

Smash said:


> Intubated, size 9 tube,


 
Size 9 tube?



> CPR continued, epi 1mg given with no change. Intubated, size 9 tube, no extensions or so forth to minimize dead space in the circuit. Initial end tidal of 160mmHg, SpO2 of 77%. Ventilated at a rate of about 6/min with a Vt of about 8-10ml/kg. ILS crew continued giving epi and CPR under direction.


 
What was the PetCO2 during the cardiac arrest?

Where was the pulse ox placed?


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## Melclin (Nov 9, 2009)

VentMedic said:


> If this patient is hyperinflated with a bronchospasm, the chances of bagging with much to any Vt will be slim to nil without excessive pressure which will of course cause the pneumos.



Gotcha. That makes sense. What role does gastric insufflation play? Surely you'll be inflating the stomach long before an iatrogenic pneumo.  



> If the patient has bilateral tension pneumos, the chances of ventilating with PIPs of less than 60 cmH2O would not be likely. Of course, even with the pneumos decompresssed the inflammation and bronchospasm will persist and if it is servere enough to cause the patient to code one still won't be able to bag unless they happen to be carrying heliox on their truck.



You mean positive inspiratory pressure (PIP) right? Not P1P (intrapleural pressure). You meant that you will likely need to provide >/= 60cmH2O of pressure to overcome the compression caused by the tension pneumo? Just checking, I'm no RRT.

How useful is heliox in this situation? It makes good sense, being a lower density, and it obviously has some mesurable desirable effects, but everything I've read has said that the evidence just isn't there that it improves outcomes (although there does seem to be a distinct lack of evidence in general regarding heliox's use in ventilated pts). Do you use it to aerosolise medications as well?

EDIT: Our guidelines still say to ventilate everyone with Vt of 10ml/kg although we have all been instructed that 6-7 are better numbers. Why such high numbers if the normal Vt is more like 3-5? Any idea why our service keeps pushing this idea of 10mls/kg despite the fact that it seems to be way too much and impossible for us to measure.


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## VentMedic (Nov 9, 2009)

Melclin said:


> Gotcha. That makes sense. What role does gastric insufflation play? Surely you'll be inflating the stomach long before an iatrogenic pneumo.


 
The ETT size 9 was mentioned. But you are correct that the belly would be well ventilated and unless an NG or OG was placed, that also would further impede ventilation. 




Melclin said:


> You mean positive inspiratory pressure (PIP) right? Not P1P (intrapleural pressure). You meant that you will likely need to provide >/= 60cmH2O of pressure to overcome the compression caused by the tension pneumo?


 
Either a pneumo or bronchospasm will cause a dramatic increase in PIP (Peak Inspiratory Pressure).



Melclin said:


> How useful is heliox in this situation? It makes good sense, being a lower density, and it obviously has some mesurable desirable effects, but everything I've read has said that the evidence just isn't there that it improves outcomes (although there does seem to be a distinct lack of evidence in general regarding heliox's use in ventilated pts). Do you use it to aerosolise medications as well?


 
There is definitely not a lack of evidence for heliox and ventilated patients. Over the past 25 years, there would have been many more deaths due to asthma if heliox had not been used with the ventilator. As well, it has kept many patients from being intubated.   

http://scholar.google.com/scholar?q=heliox+ventilator&hl=en

http://search.aarc.org/search?clien..._occt=any&as_dt=i&as_sitesearch=&sort=&as_lq=

http://ajrccm.atsjournals.org/cgi/s...edef=1+January+1994&tdatedef=15+November+2009



> EDIT: Our guidelines still say to ventilate everyone with Vt of 10ml/kg although we have all been instructed that 6-7 are better numbers. Why such high numbers if the normal Vt is more like 3-5? Any idea why our service keeps pushing this idea of 10mls/kg despite the fact that it seems to be way too much and impossible for us to measure.


 
10 ml/kg is a middle of the road number. 12 ml/kg had been considered the norm and is the number many of the studies use. Anesthesiologists and organ procurement teams still prefer 12 - 15 ml/kg as many CT surgeons had in the past. For an ARDS prtocols we will rarely run less than 6 ml/Kg and that is generally with much higher levels of PEEP. If we do run at 6 ml/kg and the patient is spontaneously breathing, deep sedation and a paralytic may be necessary to prevent the complications of low VT ventilation by over breathing. Of course, atelectasis is also a complication of VT ran too low for extended periods of time like more than 1 hour. Attempting to run a low VT protocol without a very good graphics setup on a very good transport ventilator would be very difficult and probably a little dangerous unless it is the only way you can ventilate the patient due to increased airway resistance. Then, the ventilator should have some monitoring capabilities. 

http://www.ardsnet.org/system/files/Ventilator+Protocol+Card.pdf

http://www.ardsnet.org/


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## Smash (Nov 9, 2009)

Melclin said:


> How did you work it like that being an EMT-B, do you mean that you were with a medic who did that, or are you telling little phibs about your level of practice? Student maybe?


 Qualifications changed; it's all about the badge and status 



> Vt seems a little high even for a normal pt. Were you wanting to increase the Vt in an asthmatic arrest? I would have thought you'd back off on the Vt what with dynamic hyperinflation and so on...focussing more on the expiratory phase. With their functional residual capacity through the roof you don't need to be overloading them.



Vt should probably be a bit lower and probably was.  Bearing in mind that this is with hand operated recoil bag it is difficult to judge.  Rate was only around 6, so allowing time for expiratory phase of the cycle, and this is actually lower than the recommended by the ERC, however it was judged to be appropriate in this instance.

PIPs is peak inspiratory pressure.  An orogastric tube as placed as soon as possible following intubation and the stomach decompressed.  The lower oesophageal sphincter tends to have poor tone in these situations, so it is highly likely that it will be over inflated.




> Size 9 tube?



Yes.



> What was the PetCO2 during the cardiac arrest?
> 
> Where was the pulse ox placed?



EtCo2 levels as noted, ILS do not have capnography, so numbers unknown until immediately before and after intubation.  Spo2 probe placed on an earlobe.

Anyway, ongoing treatment was:  Infusion of IV beta-agonists.  Sedation and paralysis with therapeutic hypothermia.  There continued to be some free air via the pneumocaths, however ventilation considerably easier.  BP and HR trended towards normal, EtCo2 eventually down to 100mmHg on arrival at hospital.

12 days in ICU and the patient was discharged to home, neurologically intact and with no ongoing health issues as a result of this episode.


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## VentMedic (Nov 9, 2009)

Smash said:


> EtCo2 levels as noted, ILS do not have capnography, so numbers unknown until immediately before and after intubation. Spo2 probe placed on an earlobe.


 
Interesting.



Smash said:


> Anyway, ongoing treatment was: Infusion of IV beta-agonists.


 
What country are you working in?



> 12 days in ICU and the patient was discharged to home, neurologically intact and with no ongoing health issues as a result of this episode.


 
How was his voice after a size 9 through his cords?


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## Melclin (Nov 9, 2009)

Very illuminating as usual. Thank you. Very interesting about the different Vt's, we are evidently not being told the whole story. Another trip to the med library may be in order. 

On the topic of Heliox (I'm cerntainly not questioning your knowledge on the topic, I'm just trying to reconcile it with what I've read), I read many of those articles listed in those searches. I've not studied them carefully, so maybe I've missed the point. I might point out though that many of those articles weren't not specific to asthma.

As I said, and as many of the articles in the searchs you listed note, there are notable changes in desirable physiological effects, but most reviews seem to go on to say that this has not translated to a difference in outcome.



> Finally, one may ask whether there is a role for heliox in mechanically ventilated patients. Studies by Menitove and Goldring10 and Darioli and Perret11 have demonstrated that mortality from mechanical ventilation for asthma can be eliminated using techniques to reduce dynamic hyperinflation. No similar data exist for heliox when it is used in such cases.


Manthous CA. Heliox for Status Asthmaticus? Chest. 2003 March 2003;123(3):676-7.



> The existing evidence fails to demonstrate a clear benefit from the administration of helium-oxygenmixtures to all ED patients with acute asthma.
> Treatment with heliox may improve pulmonary function in the most severe acute asthma patients; however, clinicians must ensure other evidence-based treatments are employed.


Rodrigo Gustavo J, Pollack Charles V, Rodrigo C, Rowe Brian H. Heliox for non-intubated acute asthma patients. Cochrane Database of Systematic Reviews [serial on the Internet]. 2006; (4): Available from: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002884/frame.html.

I know this is for non-intubated pts, but it was one of the articles I read that generally pushed me in the direction of thinking that some of the evidence for heliox improving outcomes might be a bit soft.



> Despite the lack of concrete evidence to support its use in asthma, Heliox still forms an integral part of the treatment algorithms for exacerbations of asthma in some centres....There also exists a small population of patients with status asthmaticus who fail to respond to routine therapy but still have respiratory muscle reserve. It is this second group who they may benefit from breathing Heliox until definitive therapies take hold.


Reuben AD, Harris AR. Heliox for asthma in the emergency department: a review of the literature. Emerg Med J. 2004 March 1, 2004;21(2):131-5.

Reuben etal go on to talk about Bridgeport Hospital, Connecticut and their asthma protocols which involve heliox only for serious asthma that does not yet require mechanical ventilation.


I wasn't talking _generally_ about heliox I was talking specifically about this case. Many of those articles were about heliox in general and I do know how to use an internet search function. Given the articles I've just cited, its not so silly on my part to be asking the question. I'm certainly not against the idea of heliox, I think with the right study design it would prove to be quite helpful in this context, I was commenting on the lack of evidence for its use in this case specifically. But again I'm no expert, if there's something out there I'd really like to see it. I was looking into the possibility of writing a brief outline of its possible uses in pre-hospital settings for a local publication but was disappointed to find a lack of _strong_ evidence for its use, so if you know of something do tell.

Do you feel that the evidence that exists is enough to warrant its use in selected situations in a pre-hospital setting?


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## Smash (Nov 9, 2009)

VentMedic said:


> How was his voice after a size 9 through his cords?



As dulcet as always.  At 300lb and 6'6" he could have had a garden hose down there and not noticed the difference.


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## VentMedic (Nov 9, 2009)

Melclin said:


> Do you feel that the evidence that exists is enough to warrant its use in selected situations in a pre-hospital setting?


 
It would be impractical in pre-hospital due to the flow factor of heliox and the amount of tanks you might have to carry.  For 70/30 you multiply the number set on the flowmeter by 1.6 and for 80/20, 1.8.  Thus, the flow is almost 2x for your tank calculation purposes.   Putting an H tank on your truck might not be practical. 

The articles you cited did make an argument for heliox.  As one stated, not "all" ED patient will get heliox.  It will depend on the Peak pressures, A-a gradient and the technology available.  Not all ventilators are compatible with heliox.  

I also did not just do a general internet search but gave you links from the Respiratory Care journal for U.S.  RTs and the ATS journal for pulmonologist and critical care physicians.   Many do not know about these journals if they are from other countries.


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## VentMedic (Nov 9, 2009)

Smash said:


> As dulcet as always. At 300lb and 6'6" he could have had a garden hose down there and not noticed the difference.


 
Fat or muscle does not count for ideal body weight.  The length should not be an issue with an 8 unless you nasally intubated which I hope you didn't with a size 9.  Granted I would not put a 7 in but an 8 would be adequate especially with today's modern ventilators. My apologies if your hospital are not that advanced to overcome ETT resistance. 

I haven't seen a regular size 9 ETT used except for vetinary medicine and for special OR and ICU procedures where the tube is carefully placed with a videoscope under very ideal situations.


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## VentMedic (Nov 9, 2009)

Smash,
I ask again, what country are you from so we can get a better idea about your training, available meds and protocols especially since you did mention the IV beta agonists?


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## Melclin (Nov 9, 2009)

> Qualifications changed; it's all about the badge and status





> Smash,
> I ask again, what country are you from so we can get a better idea about your training, available meds and protocols especially since you did mention the IV beta agonists?



Its not about being fickle. I'm not going to have a go at you about which ticket you have. But its a legitimate question. If you're marked a a B and you're practicing as a P it stands to reason that people will be interested in the why.

Also its helpful in this particular case. I'm a little confused about what happened when, so I was just interested to know to add a little clarity and as Vent said, it'd would be interesting to know a little about where u are in terms of protocols and so on.


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## Smash (Nov 10, 2009)

At the moment I'm lying on a beach in Thailand. Really, where I am or what level of training I identify myself as has no bearing. The scenario was as stated and I was curious to know what people would do and why. Fashions may vary from country to country, protocols may differ, training may not be standardized, but none of that interferes with the discussion of the case or the science (or lack of) behind such treatments. For example, intravenous beta agonists do not find favor in many places and for sound reasons, however in others they are recommended for refractory bronchospasm, and there are also reasonable grounds for this.  

What was done was done, and in this instance it had a favourable outcome. I'm happy to hear critique of the actions of the crews in this instance, and I would be happier finding out how others would approach such as case. Thus far I've discovered that most people would just call the undertaker! That and perhaps a 9mm ETT is a good size tube for a horse (or maybe a man built like a horse...) I'm fairly sure that the patient and his family are reasonably hOly that the undertaker wasn't the first option here!


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## VentMedic (Nov 10, 2009)

Smash said:


> At the moment I'm lying on a beach in Thailand. Really, where I am or what level of training I identify myself as has no bearing. The scenario was as stated and I was curious to know what people would do and why. Fashions may vary from country to country, protocols may differ, training may not be standardized, but none of that interferes with the discussion of the case or the science (or lack of) behind such treatments. For example, *intravenous beta agonists do not find favor in many places and for sound reasons*, however in others they are recommended for refractory bronchospasm, and there are also reasonable grounds for this.


 
You obviously don't understand there is more than just "different protocols" just based on level of training concerned here. 

Example: Australia has the chest compression or squeeze method while we are still trialing it in the U.S. at select facilities.

IV beta agonists: That would depend on the medication. There has been a lot of literature on this subject. We've also had discussions about using them for asthmatics with H1N1 to reduce the risk of exposure to health care providers. However, the literature isn't favorable and one of the better medications, albuterol, is not approved for IV use except in a few countries and those are the ones who have produced the literature. If you are using something different or have evidence to prove otherwise, I'm sure others would like to hear about it. 

There are also varying views by country for just doing bilateral decompression. 

Another example: the treatment of asthma differs from the Pulmonology Society in each country with different recommendations from NZ/AU, EPR-3 (U.S.), ERS and Canada. Thus, EMS in the U.S. may adopt recommendations from these authorities for their treatment such as the use of compressions, sterioids, and mag in the field as well as IV albuterol if it is approved in that country. 

You initiate a scenario but can not answer simple questions when asked and get defensive or embarrassed when someone asks about your country or level. That sounds like you are not comfortable with your title and you probably should continue your education so you will understand why some of these questions are relevant to patient care. Even as an EMT-B, one can be advanced enough in education regardless of level to at least answer what country they are citing protocols from and explain a few things concerning treatment. That is what this thread is about and not your ego or beach time in Thailand.

One more question:  Did you use 300# as the ideal body weight for calculating VT or did you use the height?


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## Melclin (Nov 10, 2009)

*Just thought I'd add this in an asthma dicussion*

Oh wow, I didn't realise you guys didn't have IV salbutamol.

Certainly 'gentle lateral chest pressure' is a controversial one. It was almost removed from the guidelines a while ago. A doctor, I believe it was Frank Archer, our current professorial head of department at uni, did some sort of study, not particularly well weighted..case control study I think it was, and apparently it showed impressive results, so it was retained. 

Considerable ambiguity abounds throughout the state service about what exactly 'gentle lateral chest pressure' involves. I don't know why. It's not a hard idea to communicate. Some people insist on performing it almost like chest compressions which is quite silly and most probably dangerous. 

The hands are applied to the chest; bottom of the palms roughly at the level of the floating ribs, thumps pointing to the ziphoid process, along the lines of the false rib's cartilaginous connections; index finders pointing roughly towards the nipples; and apply a gentle 'inwards and upwards' pressure. 

This is the guideline (a bit old now, but still essentially the same, except that hydrocortisone has been replaced by dexamethasone, and that the COPD guidelines have been separated from the asthma guidelines) if anyone is interested in our approach, or the use of IV beta agonists:
http://www.rav.vic.gov.au/Media/doc...0906-3c3be645-b626-4222-bed6-47076bae9ca1.pdf


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## Melclin (Nov 10, 2009)

*A little something from the Aussie perspective*

http://www.anzca.edu.au/jficm/resources/ccr/2005/june/Salbutamol.pdf --Australian paper arguing against the use of IV salbutamol.

http://www.nationalasthma.org.au/cms/index.php
--Current recommendations of the the (Australian) National Asthma Council

http://www.anzca.edu.au/jficm/resources/ccr/1999/december/Asthma.pdf
--The typical Australian clinical approach.


A couple of radomised control trials comparing IV and nebulised salbutamol, which seem to be referenced here as the big two:

Swedish Society of Chest Medicine. High dose inhaled versus intravenous salbutamol combined with theophylline in severe acute asthma. Eur Respir J 1990;3:163-170.

Salmeron S, Brochard L, Mal H, Tenaillon A, Henry-Amar M, Renon D, Duroux P, Simonneau G. Nebulized versus intravenous albuterol in hypercapnic acute asthma. Am J Respir Crit Care Med 1994;149:1466-1470.

Our guidelines state that IV salbutamol has no advantage over nebulised salbutamol and that it can in large doses cause intracellular acidosis. This seems to be supported by this literature.


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## Smash (Nov 16, 2009)

VentMedic said:


> You initiate a scenario but can not answer simple questions when asked and get defensive or embarrassed when someone asks about your country or level. That sounds like you are not comfortable with your title and you probably should continue your education so you will understand why some of these questions are relevant to patient care. Even as an EMT-B, one can be advanced enough in education regardless of level to at least answer what country they are citing protocols from and explain a few things concerning treatment. That is what this thread is about and not your ego or beach time in Thailand.
> 
> One more question:  Did you use 300# as the ideal body weight for calculating VT or did you use the height?



I love it!  Not a single thread can go by without snide comments, insinuation and snarky little asides can it?

In terms of this scenario, it is reasonable to assume that the treatment that was carried out was in accordance with local protocol.  Knowing for example that I work for the Olomouc Ambulance Service in the Czech republic makes absolutely no difference, unless you happen to have an in-depth knowledge of such protocols to be able to critique what was done in accordance with them.  However, it is still possible and indeed desireable (as I was attempting) to find out what others would do in such situations, and to critique the treatment in terms of what is generally accepted in whatever region you come from.  I would not have thought that would be too difficult.

If you want to know what beta-agonist was used, you need merely to ask.  If you want to know what instruments were used, you need merely to ask.  If you want to know on what evidence our protocols are written you need merely to ask.  
What geographical, political, religious or other milieu this takes place in is utterly irrelevant in terms of a clinical discussion.

What qualification level or word salad I post after my name also has no bearing.  We have in this forum people who identify themselves as having a high level of training/education/experience coming out with such gems as (and I paraphrase here) "Versed doesn't stop seizures it just relaxes the muscles" and "hyperventilating patients have too much oxygen in their systems which makes them posture"
Quite frankly, I'm happier not being identified with such levels of training and prefer to have clinical discussions that can be judged on their merits, not on who types things.  Listing qualifications is irrelevant for a number of reasons: 1: it does not actually mean the person has any idea what they are talking about (see above) so are irrelevant) 2: There is no way of knowing whether these are real qualifications, gained at real universities.  I could be the head of Trauma Surgery at a major trauma center, or I could be the cleaner.  It makes no difference to the discussion.

It would seem to me that someone who is happy with their level of training/education/experience and so forth would not feel the need to be abusive and make personal attacks and could hold a rationale, polite conversation without the need to resort to such obfuscation and intellectually devoid tactics.  I realise that fragile egos require frequent stroking, however mine doesn't. 

Seeing as there was a straightforward question asked:  I use patient's height in centimetres, minus 100 as the ideal bodyweight in kilograms.

MelClin, we too do not use IV beta-agonists if there is adequate air-movement to have an effect with inhaled agonists.  However we do not currently have the option of including nebulized medications through a ventilation circuit.  We are also very, very wary of using IV beta-agonists in the chronic obstructive patient.

And now, as I am no longer on the beach in Thailand, but rather in the hill country in the north, I am going to lie beside the pool for the rest of the day.


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## BLSBoy (Nov 16, 2009)

Smash, if you would quit dodging, and just ANSWER the questions, then there wouldnt really be much of a problem.


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## mycrofft (Nov 17, 2009)

*Pareto Principle At Work*

As well as Heinsenberg's, and the Principle of Four.

Mycrofft, Dark Overlord of the Universe.


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## Smash (Nov 17, 2009)

BLSBoy said:


> Smash, if you would quit dodging, and just ANSWER the questions, then there wouldnt really be much of a problem.





			
				Smash said:
			
		

> *I work for the Olomouc Ambulance Service in the Czech republic*



Now, can you answer a question of mine?  In what way does knowing the above information change the question of how other people would have treated this patient?

The only question that I "dodge" are the ones that make no difference to the discussion.  The case was laid out, what was done was laid out, what happened was laid out, and all that I ask is then what would others have done in such a situation.  If someone wants to know why something was done, that is fine, I will answer it.  If someone wants to know specifics of what drugs were used I will answer that.  Fortunately some such as MelClin are able to answer that question and contribute from an Australian perspective, however others are clearly too tied up in where I am from and what training I have.  I can only speculate as to why this is so important to some, and I've addressed this already; it quickly becomes tiresome when an interesting clinical discussion could be had and instead we get bogged down in such ridiculous irrelevancies.  You may as well ask what kind of ambulance was driven to the case for all the difference it makes to the clinical discussion(Mercedes Sprinter van by the way <_< )


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## akflightmedic (Nov 17, 2009)

I am with you...at no point does your level of training nor your location have impact on the discussion. You asked people what they would do and those responses should be based around what they do or know in their area of operation.

Obviously by your discussion you do indeed have some knowledge, training and experience other than google, which is commendable. 

I think a few people need to reexamine their selves and get on board with the discussion points which are relevant.


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## VentMedic (Nov 17, 2009)

> MelClin, we too do not use IV beta-agonists if there is adequate air-movement to have an effect with inhaled agonists. However we do not currently have the option of including nebulized medications through a ventilation circuit. We are also very, very wary of using IV beta-agonists in the chronic obstructive patient.
> 
> And now, as I am no longer on the beach in Thailand, but rather in the hill country in the north, I am going to lie beside the pool for the rest of the day.


 


akflightmedic said:


> I am with you...at no point does your level of training nor your location have impact on the discussion. You asked people what they would do and those responses should be based around what they do or know in their area of operation.
> 
> Obviously by your discussion you do indeed have some knowledge, training and experience other than google, which is commendable.
> 
> I think a few people need to reexamine their selves and get on board with the discussion points which are relevant.


 
Then why didn't Smash want to answer a few simple questions like what country he is from and what beta agonists he is using IV? 

This has been the subject of lengthy discussions in the U.S. and it wouild be nice to know what others are doing if it could be beneficially implimented into their own protocols. Why do some have to be so closed minded and not look outside of their own recipe book? Is that what a scenario is for? To also share ideas? Or, has this forum become so rigidly idiotic that even asking a question about a medical practice in another area is ridiculous? 

Is it really too much to ask? He brings things up but can not or won't give any further information. What's the point of doing a scenario if he can not even answer what country he are from and a few, very few, simple questions? Was he ashamed of being from the Czech Republic? 

Do some not even understand the differences in medication approval as it varies from country to country? Do you not see the revelance of being curious as to what is approved in another country that will later affect protocols in the U.S. Are some really that closed minded to learning something different or is it the fear of the moderators slapping you with a violation for asking a medical question that they may not know enough about to even see the revelance of it?

Just being a smart arse when asked questions does little for one's credibility. If you don't know something, just say so. Someone else might have the answer to the question for that area and their scope of practice. 

This forum has really gotten to a low level when questions about medicine and level of care are not or should not be asked because it might hurt an EMt-B or FR's feelings. 

*akflightmedic,* I am surprised at you for criticizing those of us who want a little more information on issues that are also controversial in this area. Have you also become so complacent to things that could impact protocols in the U.S.? Medicine is constantly changing and even though EMS is reluctant to change, you should close off your mind to where you next set of protocols come from be it next week or 10 years from now. Please don't close off you mind completely to alternative ways of doing things even if they are not currently in your own protocol book.


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## akflightmedic (Nov 17, 2009)

Not closed off at all but am dismayed at the attack bandwagon which occurred.

The few little snips here and there/badgering was unwarranted. If one chooses not to answer, it is their thread to not do so, especially if it is not entirely relevant to the scenario being presented.

While yes there is/was a learning opportunity there, maybe it was not the time to receive it. I think he did a nice job trying to steer his thread and his scenario to garner different approaches to this situation. However, one person made a few questions and then others jumped on board with nothing more to add constructively other than to try and call out or discredit...who knows.

So in short, maybe it was the "tone" of gathering more information as opposed to the simple request for curiosity and improvement.


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## VentMedic (Nov 17, 2009)

akflightmedic said:


> Not closed off at all but am dismayed at the attack bandwagon which occurred.
> 
> The few little snips here and there/badgering was unwarranted. If one chooses not to answer, it is their thread to not do so, especially if it is not entirely relevant to the scenario being presented.
> 
> ...


 
Maybe if he hadn't been so evasive when asked simple questions it would not have lead down that path. 

When there truly is an exchange of ideas within the scenario and discussion is allowed, you tend to get a better response. Just reading a recipe is not very interesting nor is the fear of being reprimanded each time you stray from that recipe. There should be encouragement, especially to those just starting, that medicine should be about learning and not just memorization of a feel notecards and a recipe book. It is a shame that this is the way EMS has gone and it also looks like the Czech Republic has similar attitudes toward education if Smash is the star example. 

Those who also tend to read "tone" into messages on an anonymous forum are also dealing with their own insecurities and issues. A web page will not hurt you. You just don't read what or who you don't like. There is nothing to be afraid of except the moderators who have their own issues.


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## akflightmedic (Nov 17, 2009)

VentMedic said:


> Those who also tend to read "tone" into messages on an anonymous forum are also dealing with their own insecurities and issues. A web page will not hurt you. You just don't read what or who you don't like. There is nothing to be afraid of except the moderators who have their own issues.



Are you really starting into me now as well? Because I infer "tone" in people's postings and call it out you insinuate I am dealing with issues and insecurity? 

Tone and context while sometimes missed is easily identified other times. There are no issues with my reading comprehension and I do not think I inferred incorrectly. 

Thank you for the free psychoanalysis and please move along now cause I think all my issues have now been identified, so there is nothing more here for you to do.


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## MrBrown (Nov 17, 2009)

VentMedic said:


> A web page will not hurt you...



Have you checked your security software lately? :lol:

Seriously tho a very interesting discussion.  Interestingly one service here uses IV salbutamol and mag while the rest don't citing lack of evidence of effectiveness.


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## Smash (Nov 17, 2009)

And still no-one has answered my question: In what way does knowing the above information change the question of how other people would have treated this patient?



> This has been the subject of lengthy discussions in the U.S. and it wouild be nice to know what others are doing if it could be beneficially implimented into their own protocols. Why do some have to be so closed minded and not look outside of their own recipe book? Is that what a scenario is for? To also share ideas? Or, has this forum become so rigidly idiotic that even asking a question about a medical practice in another area is ridiculous?



I am worried about reading comprehension on these boards sometimes.  The reason I posted this scenario was to find out what other people would have done.  Not a difficult question, but apparently beyond many.  The medical practice was clearly laid out.

Just a quick recap:  Here were some clinical questions:  





> Size 9 tube?
> 
> What was the PetCO2 during the cardiac arrest?
> 
> Where was the pulse ox placed?



These questions were answered on Page 3, post number 28.

The following however, is not a clinical question:  





> What country are you working in?



Thus I am not interested, as it has no bearing on the clinical scenario.

If you wanted to know what IV beta-agonist was used and on what basis, the ay to ask that would be:  "What beta-agonist do you use intravenously?  What is the rationale?"  

However, all we get instead are incessant abusive, belittling and worthless personal attacks apparently without any critical thinking or analysis being able to be undertaken.  It reminds me a a quote by the great Peter Medawar:  "The spread of secondary, and latterly of tertiary education has created a large population of people, often with well developed scholarly and literary tastes, who have been educated far beyond their capacity to undertake analytical thought"


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## Melclin (Nov 17, 2009)

For god sakes, why is this such an issue. 

I was just curious about what level you were at primarily just as an aside, because I was wondering why you called yourself an EMT-B when you clearly were practicing at a higher level. 

The difference in approach is not simply a matter appraising the evidence. It should be, but it isn't. Where you're from comes into it, and when you've having discussion with people about certain topics then it nice to know their background.

If we were having a discussion about a hypotensive trauma pt and someone came along and said well I would pump them full of Aramine, then it might be interesting to see what factors influenced that decision, considering that it is not the paradigm where I come from. You would probably find that the person had a background as a trauma or theatre nurse. If I said something about using IV salbutamol, the instant way of qualifying that, would be to refer to my geographical location and that would clear up any misunderstandings.

It's not a crucial part of the discussion, but its a simple and interesting question. Apart from the fact that people may just be interested in you, it does have some relevance to the discussion. 

As Vent points out the subject of levels of education is something that comes up a lot and, again as an aside, I at least, was just curious to see what education you had to be practicing at the level you were. It wasn't so I could then criticize you, I was just curious.

Bloody hell mate, we we're just asking. I can't help but think that you saw in the question the suggestion that vent was ganna rip you a new one for being un-educated and you responded by being argumentative. 

Mostly when people ask irrelevant questions they get answers unless the answer is somehow sensitive in which case they get blown off with the pseudo answer that question is irrelevant. Either you are carrying a grudge about the re-current "training levels" debate here and felt like having it out, or you are in some way ashamed of the answer to the question. 

If you didn't have some issue with it, you would simply have said something like, "Oh well I don't see how its relevant, but I'm and EMT-B and medic student on my clinicals".


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## Melclin (Nov 17, 2009)

> The following however, is not a clinical question:
> Quote:
> What country are you working in?



Well it is if you are interested in the differences in standards of care in different locations. You might not be interested in that, but others might be. I certainly am. 

The differences in care across different locations are often not just to do with empirical evidence published in journals. It has to do with all kinds of factors (usually to do with politics, personal grudges and the personal experience of the higher ups invovled) that are also interesting to discuss. Because of this geographical location is important.


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## VentMedic (Nov 18, 2009)

akflightmedic said:


> Are you really starting into me now as well? Because I infer "tone" in people's postings and call it out you insinuate I am dealing with issues and insecurity?
> 
> Tone and context while sometimes missed is easily identified other times. There are no issues with my reading comprehension and I do not think I inferred incorrectly.
> 
> Thank you for the free psychoanalysis and please move along now cause I think all my issues have now been identified, so there is nothing more here for you to do.


 
Wow!  Such sensitive types!   


Again, don't be afraid of the big words or the medical tone and language in my posts.  If you are, just put me on you ignore list as I really don't care to argue with someone who sees not relevance to any of my medical questions.


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## akflightmedic (Nov 18, 2009)

Sensitive, no. Irritated, yes. It was you who called me out and stated I had issues.

At no time have I ever been afraid of your big words, medical knowledge or anything else. I do enjoy reading your posts and have learned lots. However, a slight disagreement and you are now the one over reacting, insulting (again) and basically saying stay away if you have a different opinion.

I stated why I felt it was irrelevant, you stated why you felt it was relevant. I still do not agree, however you going off and insulting me twice indicates possibly the issue does not lie with me...just sayin.

Ego check...aisle 3 please.


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## DigitalSoCal (Nov 18, 2009)

I know I'm a newb on this board and my opinion likely means nil to anyone else, but my god what a way to take an interesting and informative discussion and send it right down the drain.


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## VentMedic (Nov 18, 2009)

akflightmedic said:


> Sensitive, no. Irritated, yes. It was you who called me out and stated I had issues.
> 
> At no time have I ever been afraid of your big words, medical knowledge or anything else. I do enjoy reading your posts and have learned lots. However, a slight disagreement and you are now the one over reacting, insulting (again) and basically saying stay away if you have a different opinion.
> 
> ...


 
Over reacting?  Why are you stuck on this person's EMT-B status?

My questions were concerning what country and what protocols for IV beta agonsts.  Why are you taking such an issue with that?  Do you not realize that medications vary from country to country and that the U.S. is also conducting research in these areas for their usefulness?  Why are you being so closed minded to think everyone is just picking on EMT-Bs?  

Why are you continuing to bash me for ask pertinent medical questions?  If you can not answer my questions, don't respond.  You have offered nothing in the line of medical information.   Get over that EMT-B thing.  The country and the medications were the issue.   If you didn't understand the IV beta agonst question, you didn't have to respond by attacking me.  

Again, just put me on your ignore list because it is obvious you have nothing I want to read any longer.   It is a shame your attitude has gone by the way of the rest of this forum when it comes to discussing medical issues.


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## akflightmedic (Nov 18, 2009)

Yes, over reacting...just read your previous posts for clarification.

Not once did I say I am stuck or indicate concern about his status. I conveyed the message that his status and location is irrelevant for what he (the original poster) wanted out of you (the responders to his scenario).

Do I realize medications vary country to country...let's see, I have worked in Iraq, Afghanistan and the Philippines...nope I never knew that. Never mind that I work at a very large NATO base and interact with multiple providers on a recurring basis including the Dutch, French, Germans, Canadians, Bulgarians, Poles, Aussies, Kiwis, and the UK to name a few. We conduct joint training exercises/discussions, etc...

Close minded? I am one of the most liberal guys I know who constantly reminds himself to not be close minded, to explore other perspectives and encourage personal development and growth through such exercises. I have taken multiple beatings on other forums because of my views. At what point did I say you were picking on an EMT B? Please quote for effect, but I doubt you will find it.

To reiterate I said it had no relevance to the way the discussion was supposed to go.

Bashing you? Umm, I just responded to YOU insulting me twice and now three times for simply having an opinion which differed from yours. Where is the open mindedness?

No, I have not offered anything medical in this thread but as I said earlier I have enjoyed reading the posts, including yours and benefiting from them. However when the topic went on a tangent as they often do, it was then that I felt the need to offer my opinion which clearly everyone else had a right to do so as well. Sadly, mine was the minority and not in tune with yours, so I am just bad, bad, bad.

You then make the statement that I did not understand something (indicating ignorance or stupidity, your pick) as a reason for attacking you. Yet again, YOU are the one who threw the gauntlet down and my response about the line of questioning had nothing to do with my understanding or "not understanding" as you assume about the IV beta agonists. When have I ever responded in a malicious way because of my own lack of knowledge. Get over yourself and stop insulting me (yet again).

I do not use ignore lists as I read everything possible. To do so is to be close minded and petty but you seem to enjoy that as you have offered it twice thus far. That is not my solution to the issue at hand.

In closing, your closing to be exact...you insult me yet again.


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## boingo (Nov 18, 2009)

Interesting case.  Once the airway was secured I would have likely ventilated the pt with lower tidal volume, more in the range of 5-6 ml/kg lean body weight and at a rate of 6-8 min.  In addition to in-line albuterol, I'd hang a Mg drip, IV epi and if the patient had any respiratory effort, I'd sedate and paralyze to take the patients diaphragm and intercostals out of the equation.  I'd also give a fluid bolus as these patients tend to be on the dry side, and with the hyperinflation venous return is decreased, more so once the patient goes from negative pressure to positive.  If after this I still had an arrested pt w/very poor compliance, I think a needle thoracostomy would be appropriate, and with the improved compliance and ROSC, a dx of tension PTX would be assumed.  This patient would also get hypothermic therapy, assuming she/he remained obtunded after ROSC.


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## Smash (Nov 20, 2009)

boingo said:


> Interesting case.  Once the airway was secured I would have likely ventilated the pt with lower tidal volume, more in the range of 5-6 ml/kg lean body weight and at a rate of 6-8 min.  In addition to in-line albuterol, I'd hang a Mg drip, IV epi and if the patient had any respiratory effort, I'd sedate and paralyze to take the patients diaphragm and intercostals out of the equation.  I'd also give a fluid bolus as these patients tend to be on the dry side, and with the hyperinflation venous return is decreased, more so once the patient goes from negative pressure to positive.  If after this I still had an arrested pt w/very poor compliance, I think a needle thoracostomy would be appropriate, and with the improved compliance and ROSC, a dx of tension PTX would be assumed.  This patient would also get hypothermic therapy, assuming she/he remained obtunded after ROSC.



Thanks boingo, good post.  We don't have the option for Mg at this stage.  IV epi was considered over the IV albuterol, however following decompression and ROSC the patient was actually hypertensive (not sure if I put that in initially)  ICU also had a lot of trouble keeping BP down.  I'm so much more used to patients having poor BPs post ROSC, particularly when on positive pressure ventilation as you mention, so I had to keep double checking   Ultimately we opted for albuterol to have the beta effects without too much alpha.

To be honest we did not initially give a fluid bolus, although we had a couple of 16g cannula running wide open to flush drugs, so I guess the same effect would also have been achieved to a point.  It's a good point though.  Our hypothermia protocol also calls for the rapid infusion of a reasonably large volume of cold crystalloids.  We also sedate and paralyze during cooling, however even if we had not cooled I agree with your decision to sedate and paralyze anyway.  This patient was difficult enough to ventilate without having to fight his own drive, and he doesn't need to have any increase in O2 demand either.

Thanks for your post.


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## VentMedic (Nov 21, 2009)

boingo said:


> Once the airway was secured I would have likely ventilated the pt with lower tidal volume, more in the range of 5-6 ml/kg lean body weight and at a rate of 6-8 min. In addition to in-line albuterol,


 
ETT? Inline neb? Low rate? Standard acorn neb?

What do you think your extra tidal volume will be with the additional flow of the nebulizer and what will actually be the particle depostion of the albuterol with a low rate? How must will be uselessly deposited within the circuit and tube? Continuos flow vent? Some questions to ponder as many others have already studied these situations to decide the benefits vs the consequences if one does not have to proper medication delivery devices. 



Smash said:


> Thanks boingo, good post. We don't have the option for Mg at this stage. IV epi was considered over the IV albuterol, however following decompression and ROSC the patient was actually hypertensive (not sure if I put that in initially) ICU also had a lot of trouble keeping BP down. I'm so much more used to patients having poor BPs post ROSC, particularly when on positive pressure ventilation as you mention, so I had to keep double checking  Ultimately we opted for albuterol to have the beta effects without too much alpha.


 
Do you understand what shifts IV albuterol can cause which is why it has been reconsidered in many situations in the countries that have been using it? Especially in a hemodynamically unstable post arrest patient whose BP can be easily influenced?

Now if either of you find any of those MEDICAL questions offensive, I will have to say this forum has lost hope of ever carrying out a MEDICAL discussion in fear that someone will get offended if they have to think a little about the questions that have been raised about certain treatments.


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## boingo (Nov 21, 2009)

In-line neb was up to recently our only option, we have since changed that to an MDI administered through a port on the circuit.  I don't know how much would actually be delivered to the target tissues, I have no way of measuring that.  As I believe someone mentioned earlier in the thread, Heliox would assist in delivering medication to the more distal airways, however pre-hospitally, the world I live in this in not an option.  My plan would be to deliver this patient in better shape than I found him to a facility equipped to manage the patient better than I.  

Do you feel an in-line nebulizer would do more harm than good in a very tight asthma pt?  I know anecdotally that in-line nebulized albuterol has improved compliance in similar patients in my experience in the past, although other medications were also in use.


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## VentMedic (Nov 21, 2009)

boingo said:


> In-line neb was up to recently our only option, we have since changed that to an MDI administered through a port on the circuit. I don't know how much would actually be delivered to the target tissues, I have no way of measuring that. As I believe someone mentioned earlier in the thread, Heliox would assist in delivering medication to the more distal airways, however pre-hospitally, the world I live in this in not an option. My plan would be to deliver this patient in better shape than I found him to a facility equipped to manage the patient better than I.
> 
> Do you feel an in-line nebulizer would do more harm than good in a very tight asthma pt? I know anecdotally that in-line nebulized albuterol has improved compliance in similar patients in my experience in the past, although other medications were also in use.


 
We now us MDIs on our vent patients as there is a concern with the extra flow.  Also, when running a low rate, you can time the delivery with the ventilation where otherwise the nebulized med might just be lost in the circuit.  There are numerous studies now on the particle depostition of both delivery methods at this has been extensively researched over the past 30+ years and now re-researched with the HFA MDIs. 

I have used a self inflating BVM to bag in a nebulized med but there I do have control over the timing and the BVM is not a continuous flow.  

Heliox would be the best choice initially in the ED and/or ICU to deliver meds and attempt ventilation.  But I believe I did mention the drawbacks to its use on a truck even for CCT/IFT.


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## mycrofft (Nov 21, 2009)

*As a "lower being", I see a real mix of art and science here.*

Looking at the "global" impacts of a tx or Rx and how it fits into a treatment regimen or protocol really drills home the need for a true education and constant ongoing education when you get past a certain point of treatment, as well as insightful examination of the pt weighed against "the need for speed" and on scene sense of urgency.

Maybe I'm shaking my rattle here, but is transtracheal still a potential route for Rx admin?

Also a sidetrack: inhaled meds in my humble experience work with an interesting lack of effect when sprayed onto mucus or phlegm-lined airways. Oh, and just as some of us "can't jump", some COPD pt's can't time their MDI sequence and need coaching or outright admin by others.


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## VentMedic (Nov 21, 2009)

mycrofft said:


> Oh, and just as some of us "can't jump", some COPD pt's can't time their MDI sequence and need coaching or outright admin by others.


 
Which is why spacers or holding chambers have been used for over 25 years on both ventilator and non-ventilated patients. As well, some BVMs have a port to enhance delivery or a small inline adapter can be ordered for use with the BVM.

The education part comes in keeping current with the new medications, new formulations (HFA vs CFC) and delivery devices. So "rig" equipment without actually knowing if it is acheiving what it is supposed to do but it "looks good".




> as well as insightful examination of the pt weighed against "the need for speed" and on scene sense of urgency.


Does that mean if the neb is ran at 10 liters instead of 6 the "need for speed" will be taken care of?


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## mycrofft (Nov 22, 2009)

*Why sure..let's see....*

10 lpm is 2/3 more than 6, so you could drive 2/3 slower to the hospital. That was easier than IV rate doseage conversions!

I'm aware of spacers, from the "Transformers" folding monstrosities to 50 cents worth of blue tubing. My rule of thumb gauge of _*efficiency*_ getting on board is how much medicine is obviously left in the spacer afer the pt does it. (My rule of thumb gauge of *efficacy* is  if the symptoms subside quickly). Some guys are all "I've been an asthmatic for twenty five years" and hit the MDI momentarily (subtherapeutic dose) after they finished inhaling (shot into their oropharynx and stayed there. just no sense of rythm, I take the time to teach em (without actually overdosing them or myself, of course). 
I can imagine the tortuous contraptions some folks try with nebs, tubing and double male adapters. Like my erstwhile coworker who reversed the tubing nipple and the intake filter fitting on the old Pulmoaid so when I set it up and turned it on it was pumping away extra hard and nothing was working..until I accidentally tipped the nebulizer handpiece while leaning over to look at the compressor.."sluuuurp".

I remembered the transtracheal deal because the one time I saw it tried during a code the young doc apparently lanced the cuff on the trache tube.


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## Smash (Nov 30, 2009)

VentMedic said:


> Do you understand what shifts IV albuterol can cause which is why it has been reconsidered in many situations in the countries that have been using it? Especially in a hemodynamically unstable post arrest patient whose BP can be easily influenced?
> 
> Now if either of you find any of those MEDICAL questions offensive, I will have to say this forum has lost hope of ever carrying out a MEDICAL discussion in fear that someone will get offended if they have to think a little about the questions that have been raised about certain treatments.



Yes I do. I also understand the need for BP Support, the vagaries of CBF, CPP, ICP post arrest and how MAP can influence these. I understand the dangers of reperfusion injuries and the need to hemodilute to mitigate the effects of the products releleased. 

Although of course post arrest patient's BP may not in fact be so easily influenced particularly given the possibly high prevalence of post-arrest adrenal insufficiency. However in this instance the patient was, and remained, hypertensive. Given that the patient still had significant bronchospasm I had limited options in managing this without causing still further undesireable increases in BP. 

See, this is how you have a clinical discussion. It doesn't require personal abuse, baseless allegations, overweening arrogance and a hectoring tone to have such a discussion. You may find if you avoid these things people will be much happier to engage in discourse.


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## VentMedic (Nov 30, 2009)

Smash said:


> See, this is how you have a clinical discussion. It doesn't require personal abuse, baseless allegations, overweening arrogance and a hectoring tone to have such a discussion. You may find if you avoid these things people will be much happier to engage in discourse.


 
The only abuse was perceived by you and your own insecurity to answer a couple of very "basic" questions.


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## Smash (Dec 1, 2009)

VentMedic said:


> The only abuse was perceived by you and your own insecurity to answer a couple of very "basic" questions.



Goodness gracious me, you really can't help yourself can you?  Is there anything else you care to make up as you go along?  

I'm assuming you don't actually have any kind of mental disability that would render you unable to understand posts or to respond to them appropriately, which leaves me at a loss as to why you keep making uncalled for, unproductive, childish and frankly ridiculous personal attacks that have no basis in the discussion at hand.


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## zmedic (Dec 1, 2009)

Going back a few pages someone noted that it isn't asthma since there was no wheezing. It's good to have a broad differential, but keep in mind that you need air movement to have wheezing, if the patient isn't moving much you won't hear much. That's why patient's often have increased wheezing in response to albuterol, because you are now getting better air flow through those lower airways. Remember, if the wheeze gets better but the patient looks worse, worry. 

Also I didn't see anyone suggesting magnesium. I know there isn't a lot of data to support it but in a crashing asthmatic who isn't responding to treatment it's worth a thought.


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## Smash (Dec 1, 2009)

The silent chest thing is something that catches a lot of people out, you are dead right.  Where I work we don't see as many sick asthmatic patients as we used to, as they are better managed by their primary care physicians with better medications and escalation strategies.

I think mag sulphate was mentioned by boingo.  We don't carry it at the moment, hence not being used in the initial management of this patient.  I was curious that it wasn't mentioned more often, it was all the rage not so long ago.


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