# 56 y/o, f



## Hunter (Jan 16, 2013)

Had a patient the other day, 56 y/o F, cc: fell down not feeling well, I wanna go to the hospital. U/A: found 56 Y/O F on the ground, managed to crawl around and grab her pillow, phone and purse, when she moves around you notice that she's deficated herself. In some distress but she's able to sit up on the ground. She's AAOx3, GCS 15, states "I felt weak and fell down, and then I couldn't get up. Denies LOC, trauma or pain anywhere.

Get her on the stretcher and in the truck vital signs where approx:
BP: 75/40, HR: 150-170, 4Lead ECG shows PSVT, 12 lead: PSVT, SAO2 94%.

How do you treat/assess?


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## Dwindlin (Jan 16, 2013)

I'm sure there is a catch, but from what you've posted here she appears unstable and is very tachycardic.  I'd address that first with cardioversion, then reassess.


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## Hunter (Jan 16, 2013)

Dwindlin said:


> I'm sure there is a catch, but from what you've posted here she appears unstable and is very tachycardic. I'd address that first with cardioversion, then reassess.


 
Yeah there's a catch, think of etiology, and instead of treating the symptom, try and find the cause. Would you ask her anything else other than the information I gave you?


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## Nattens (Jan 16, 2013)

Hunter said:


> Yeah there's a catch, think of etiology, and instead of treating the symptom, try and find the cause. Would you ask her anything else other than the information I gave you?



Looking at the causes of PSVT we've got a few possible causes

-Overexertion (Ask if an abnormal exercise, usual exercise tolerances)
-Stimulants (Alcohol, Tobacco, Coffee, Amphetamines, Cocaine. So ask if any recent ingestion of any of these substances)
-Hyperventilation (Which we would notice, what was her respiratory status?)
-Electrolyte Imbalances  and Acid Base Imbalances(Recent substance ingestion, any history of metabolic or respiratory disorders)
-Emotional Stress (Any recent changes, loss of a relative etc)

As far as treatment goes patient is rapidly detriorating so

-Midazolam 2.5mg IV repeating 2.5mg IV until patient only responds to painful stimuli
-Cardiovert 75j biphasic, if no reversion 150j biphasic
-Transport


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## hibiti87 (Jan 16, 2013)

medication list, does she take blood thinners, how long has it been going on, has she felt this way before, what does the BM look like, has she been having BMs more frequently. shes gcs 15 granted low bp, im not to concerned though, transport patient trendelenburg, start iv give fluids, reassess.

That being said i would most likely not cardiovert the patient. Afib.


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## Hunter (Jan 16, 2013)

hibiti87 said:


> medication list, does she take blood thinners, how long has it been going on, has she felt this way before, what does the BM look like, has she been having BMs more frequently. shes gcs 15 granted low bp, im not to concerned though, transport patient trendelenburg, start iv give fluids, reassess.
> 
> That being said i would most likely not cardiovert the patient. Afib.


 
Only history is of hypertension, for which she no longer takes medications because her BP was becoming too low consistently. Weakness has been going on for a few days but worsened today.


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## Hunter (Jan 16, 2013)

Nattens said:


> -Overexertion (Ask if an abnormal exercise, usual exercise tolerances)
> -Stimulants (Alcohol, Tobacco, Coffee, Amphetamines, Cocaine. So ask if any recent ingestion of any of these substances)
> -Hyperventilation (Which we would notice, what was her respiratory status?)
> -Electrolyte Imbalances  and Acid Base Imbalances(Recent substance ingestion, any history of metabolic or respiratory disorders)
> ...


 
Resp where 14, sao2 94%,
negative to all of those except, however she said she hasn't eaten in 5 days, and hasn't had anything to drink in 2-3 days.


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## mycrofft (Jan 16, 2013)

"How do you treat assess?"

(I AM controlling myself, I AM controlling myself!").h34r:


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## JPINFV (Jan 17, 2013)

Hunter said:


> Resp where 14, sao2 94%,
> negative to all of those except, however she said she hasn't eaten in 5 days, and hasn't had anything to drink in 2-3 days.



I so wanted to post, "fluids" before something like this got posted. That way I could be all smooth.


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## JPINFV (Jan 17, 2013)

Hunter said:


> How do you treat assess?


[YOUTUBE]http://www.youtube.com/watch?v=kY84MRnxVzo[/YOUTUBE]


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## Hunter (Jan 17, 2013)

mycrofft said:


> "How do you treat assess?"
> 
> (I AM controlling myself, I AM controlling myself!").h34r:


 
fixed -.-


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## hibiti87 (Jan 17, 2013)

JPINFV said:


> I so wanted to post, "fluids" before something like this got posted. That way I could be all smooth.



i said fluids before, therefore it makes me smooth?


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## abckidsmom (Jan 17, 2013)

JPINFV said:


> I so wanted to post, "fluids" before something like this got posted. That way I could be all smooth.



I try not to cardiovert someone whose volume status I'm not sure of.


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## NomadicMedic (Jan 17, 2013)

Correct. She's going to get a fluid bolus before I start messing around with rate control. 

I'd try adenosine before I lit her up. 

You said the HR is variable. Is it really SVT or is it afib with RVR.


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## Rykielz (Jan 17, 2013)

This is a very sick woman and I'd get her going asap. First thing i'd do before I left scene is grab her meds. You said she's been off the HTN RX because her BP was getting too low? That could be part of the problem today. Check her lung sounds (i=Is she SOB? Do I hear rales?). I'd look at the stool too. Is is bright red? Black? Foul or unusual odor? She could be bleeding out internally. If she hasn't eaten in 2-3 days and those are her vitals that is another red flag. I'd be cognizant of dehydration and malnutrition. Has she been vomiting as well? If so, what color is the emesis? Palpate the abd (make sure there's no pulsating masses or abnormal distention). Another great thing to grab would be her grips/pushes and have her smile for the differential diagnosis to r/o stroke. Then check her pedal and brachial (since radial probably won't be felt) to make sure they're present and equal. As far as treatment I'd do this:

           1) Place her in shock position
           2) Oxygen 15 LPM via NRB
           3) Cardiac monitor (Have my partner perform a 12-lead)
           4) Bilat. large bore IV (grab a bs as well)
           5) NS fluid bolus (That could very well correct her HR and her BP)
           6) I'd be careful with adenosine. She's unstable and this appears to be
               a hypovolemia and not a conduction issue. Cardioversion (Versed 
               beforehand for pre-cardioversion)may be the better option although
               that probably won't do much either.  
           7) Perform another 12-lead if I'm able to get the HR to slow down. This
               could very well be an MI as well.
           8) Get her to the hospital asap. She needs the higher level of care.

***I had a call very similar to this. 30-ish y/o female fell suddenly had been sob for several days. By the time we got there she was lethargic and unable to speak due to her breathing. VS: 230 HR SVT, BP 70/P, RR 60 rapid and shallow. LS were absent in the bases with rales heard in the upper lobes bilat. I ended up popping bilat. large bore IV's in her, bagging, and cardioverting her 3 times which didn't do anything. I wanted to put her on CPAP but she did not meet the criteria according to my protocols. Well when we get her to the hospital the doc put her on their CPAP and she was fixed within 10 minutes; full sentences and everything. Never had an SVT call like it since.***


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## Hunter (Jan 17, 2013)

Just to clarify we gave her 1L Fluid, which brought her BP back to about 110/60, and her pulse to somewhere around 125-130 (Don't remember exact numbers), and transported her to the hospital. We considered adenosine, but after she told us that she hadn't had anything to drink in days we decided to go with the fluid bolus. Also when she said that we checked skin turgor and it was at least 3 seconds.


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## Handsome Robb (Jan 17, 2013)

She's awake, talking moving around and you want to jump to zapping her?? 

Fluids, watch her for fluid overload, consider adenosine maybe...

Using the 220-age rule she's barely into the SVT range...


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## Rykielz (Jan 17, 2013)

Hunter said:


> Just to clarify we gave her 1L Fluid, which brought her BP back to about 110/60, and her pulse to somewhere around 125-130 (Don't remember exact numbers), and transported her to the hospital. We considered adenosine, but after she told us that she hadn't had anything to drink in days we decided to go with the fluid bolus. Also when she said that we checked skin turgor and it was at least 3 seconds.



Clearly a fluid issue then, but I'd continue to reassess and look to see if anything else was going on. Definitely a call where I'd be texting the nurse to see the outcome too.


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## Handsome Robb (Jan 17, 2013)

a





Rykielz said:


> This is a very sick woman and I'd get her going asap. First thing i'd do before I left scene is grab her meds. You said she's been off the HTN RX because her BP was getting too low? That could be part of the problem today. Check her lung sounds (i=Is she SOB? Do I hear rales?). I'd look at the stool too. Is is bright red? Black? Foul or unusual odor? She could be bleeding out internally. If she hasn't eaten in 2-3 days and those are her vitals that is another red flag. I'd be cognizant of dehydration and malnutrition. Has she been vomiting as well? If so, what color is the emesis? Palpate the abd (make sure there's no pulsating masses or abnormal distention). Another great thing to grab would be her grips/pushes and have her smile for the differential diagnosis to r/o stroke. Then check her pedal and brachial (since radial probably won't be felt) to make sure they're present and equal. As far as treatment I'd do this:
> 
> 1) Place her in shock position
> 2) Oxygen 15 LPM via NRB
> ...



May I ask why? 

She needs an ALS workup and transport to definitive care but she doesn't need you running around like a chicken with your head cut off. Despite popular belief, there's very few things where seconds truly count. 

The call you referenced is much more severe than the one originally described in this thread. 

She's dehydrated. Severely. She doesn't need medications or electricity. She needs fluids and electrolytes. 150-170 isn't that fast for a 56 year old. It's fast and needs to be addressed but she's not going to crump on you. Take the numbers you're getting and combine them with your patient's presentation and decide on the best treatment path. 

So you want to give a severely hypotensive patient versed to cardiovert her? Versed isn't as scary as medic school makes it out to be but if she's stable enough for you to mess around with getting a line and drawing narcs she's stable enough for you to start a fluid challenge and consider chemical cardioversion before lighting her up like the morning sky. 

You said you'd be wary of adenosine because "she's unstable and hypovolemic, cardioversion is a better option". How is cardioversion even an option in this instance? What is cardioverting a hypovolemic patient going to do for them other than hurt? Replace the volume, see what that does then reconsider your plan of action...

Where the heck did a CVA assessment come into play? I'm all for being thorough but nothing here says stroke to me at all. Maybe I'm missing something but you can do a pretty solid neurological assessment by just interacting with a patient. She complained of generalized weakness, not unilateral weakness....


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## PaddyWagon (Jan 17, 2013)

A basic student's guess: maybe stroke + dehydration.  See if she remembers recent headache(s), check facial droop, slurring of words, and the arm drop test.

Stroke would account for the original fall and loss of ability to get back up.  Dehydration leads to hypovolema  and accounts for the low BP.  It's possible for a stroke to build up over days, though I have to read up on how common that might be.

Am I way off base, I'm still a newbie for sure?

Here in LA county we're taught to not do Trendelenburg.

I'm going to read up on the treatments brought up even though they're way out of my scope, never hurts to know =)


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## Christopher (Jan 17, 2013)

Hunter said:


> HR: 150-170, 4Lead ECG shows PSVT, 12 lead: PSVT



Booo! Booooo! It is only "PSVT" if you watched it start and stop. That term is a bad term anyways. "Narrow complex tachycardia" and "wide complex tachycardia" are better. SVT isn't a rhythm and apparently only exists to confuse people.

If by "150-170" you meant a ranging heart rate? Only three narrow complex tachycardias meet that definition:

Sinus tachycardia
Atrial fibrillation
Atrial tachycardia (but not a huge range)
Atrial flutter with variable conduction and "150-170" is the rate displayed by the cardiac monitor's moving average (unlikely)
If by "150-170" you meant, "somewhere exactly between those two", I would add the following are differentials separated by rhythm interpretation and not by rate (ordered by likelihood given patient's age):

Sinus tachycardia
AVNRT
AVRT
Atrial flutter (2:1)
Atrial tachycardia
Junctional tachycardia


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## mycrofft (Jan 17, 2013)

CVA with these s/s seems very unlikely. Why couldn't she get up ORIGINALLY, did she get dizzy? (later on,probably). Any ortho issue which kept her from getting to the toilet, getting water and food, etc., like broken hip or a blown knee?

Saw a similar situation in a man who fell (had Parkinson's) and wedged between tub and toilet for three days, his barking dog summoned help (neighbors called landlord). Similar findings.


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## Rykielz (Jan 17, 2013)

Robb said:


> a
> 
> May I ask why?
> 
> ...



As I said cardioverting was unlikely to work. Adenosine even more so. But I work in California, which is a mother-may-I system and on that call they'd tell me to cardiovert if the fluid didn't work. Not my choice it's how my protocols are written. When I originally wrote that I did not know that the fluid had worked. Which is why the other treatments were listed. Assuming the  fluid didn't work that would've been the only option left other than continuing to pump her full of fluid.

Are you telling me that generalized weakness can not be a stroke? Not every stroke presents the same. Is it an unlikely diagnosis? Yes. Does it mean you can rule it out? Absolutely not. You cannot get tunnel vision on any call because the one time you do that'll be your license.


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## Rykielz (Jan 17, 2013)

It also says directly in our protocols Adenosine is for stable SVT. This patient is without a doubt unstable when you look at her BP.


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## Christopher (Jan 17, 2013)

Rykielz said:


> It also says directly in our protocols Adenosine is for stable SVT. This patient is without a doubt unstable when you look at her BP.



That's not exactly true.

Adenosine is for tachycardias likely to be due to reentry mechanisms, whether they are stable or unstable makes no matter for its efficacy. Adenosine will not "fix" a stable sinus tachycardia nor a stable atrial tachycardia nor a stable atrial flutter or atrial fibrillation.

I've had stable patients with blood pressures in the 60's. They were in septic shock, but answered all questions appropriately and without hesitation. They most assuredly did not need cardioversion or adenosine for their tachycardias.

You must understand that cardioversion is for patients unstable DUE to their tachycardia. If their tachycardia is a compensatory response then cardioversion (whether chemical or electrical) is CONTRAINDICATED.

Atrial fibrillation with RVR is not always the cause of a patient's hemodynamic instability. Hypovolemic patient with a GI bleed and AF w/ RVR @ 140-170 will not respond to cardioversion no matter how many times you do it. They also meet the definition of unstable...

Sinus tachycardia is never* the cause of a patient's hemodynamic instability. (* you may only replace 'never' with another word if you actually can name the forms of sinus tachycardia that may cause hemodynamic instability)

Treatment of tachycardias is not rate based nor blood pressure based nor stable versus unstable.

Treatment of tachycardias is based on the appropriate rhythm interpretation in light of the patient's clinical presentation. This is not contradictory with ACLS or Paramedic curriculum or any protocols.

I'll add that if you are electing to cardiovert a narrow complex tachycardia that is not atrial fibrillation with RVR or atrial flutter, you need to take a step back and seriously evaluate what you are doing. Narrow complex tachycardias other than those two are almost always well tolerated even for prolonged periods of time. You would be well served to have already gone down the list of fluids, valsalva, adenosine, and a really hard look at H's and T's...


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## Hunter (Jan 17, 2013)

Robb said:


> Rykielz said:
> 
> 
> > This is a very sick woman and I'd get her going asap. First thing i'd do before I left scene is grab her meds. You said she's been off the HTN RX because her BP was getting too low? That could be part of the problem today. Check her lung sounds (i=Is she SOB? Do I hear rales?). I'd look at the stool too. Is is bright red? Black? Foul or unusual odor? She could be bleeding out internally. If she hasn't eaten in 2-3 days and those are her vitals that is another red flag. I'd be cognizant of dehydration and malnutrition. Has she been vomiting as well? If so, what color is the emesis? Palpate the abd (make sure there's no pulsating masses or abnormal distention). Another great thing to grab would be her grips/pushes and have her smile for the differential diagnosis to r/o stroke. Then check her pedal and brachial (since radial probably won't be felt) to make sure they're present and equal. As far as treatment I'd do this:
> ...


 
^This was the point of the thread, figure out why the patient has the signs and symptoms that she does and treat the cause of them. 

She was alert x3, responding appropriately I'm not sure why you call her unstable, yes the vital signs aren't the best but I would consider her borderline stable.

She wasn't in respiratory distress whatsoever, she was at 94%, and respirations where 14, the O2 at 15LPM seems like a bit much and I think this is one of those situations where it would've hurt her instead of helping. 

Her BSG was normal, don't remember the exact number.

Second 12 lead was sinus-tach at about 130



Robb said:


> May I ask why?
> 
> She needs an ALS workup and transport to definitive care but she doesn't need you running around like a chicken with your head cut off. Despite popular belief, there's very few things where seconds truly count.
> 
> ...


.
Agreed with most of this, however a medial CVA would cause general weakness, but it would've also caused other symptoms which is why we didn't suspect it, dysphagia, aphagia, ect.



Christopher said:


> Booo! Booooo! It is only "PSVT" if you watched it start and stop. That term is a bad term anyways. "Narrow complex tachycardia" and "wide complex tachycardia" are better. SVT isn't a rhythm and apparently only exists to confuse people.
> 
> 
> 
> ...


It would go up and down between 150-170, once we reassessed after the fluids her heart rate was at 125-135 (as in i'm not sure what it was, but it was somewhere around there).



mycrofft said:


> CVA with these s/s seems very unlikely. Why couldn't she get up ORIGINALLY, did she get dizzy? (later on,probably). Any ortho issue which kept her from getting to the toilet, getting water and food, etc., like broken hip or a blown knee?
> 
> Saw a similar situation in a man who fell (had Parkinson's) and wedged between tub and toilet for three days, his barking dog summoned help (neighbors called landlord). Similar findings.


 
No ortho, only history was hypertension, she said she couldn't get up because she had been getting weaker over time.





Rykielz said:


> It also says directly in our protocols Adenosine is for stable SVT. This patient is without a doubt unstable when you look at her BP.


 
A BP alone is not the only thing that would determine if a patient is stable or unstable, as many EMT/Medic instructors have said, treat the patient not the monitor(sorry I know some people don't like this saying.)



Christopher said:


> That's not exactly true.
> 
> Adenosine is for tachycardias likely to be due to reentry mechanisms, whether they are stable or unstable makes no matter for its efficacy. Adenosine will not "fix" a stable sinus tachycardia nor a stable atrial tachycardia nor a stable atrial flutter or atrial fibrillation.
> 
> ...


 
I agree and fluids would be part of the H's & T's, and it's how we figured out what was wrong with her.


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## Christopher (Jan 17, 2013)

Hunter said:


> It would go up and down between 150-170, once we reassessed after the fluids her heart rate was at 125-135 (as in i'm not sure what it was, but it was somewhere around there).



This right here was your answer! A ranging heart rate + tachycardia narrows it down greatly.

You know:
(1) it is automatic not reentry (excluding the very rare possibility of flutter w/ variable conduction, but that should be obvious)
(2) it is either sinus tach or atrial fibrillation

Best to avoid "PSVT" as people like to cardiovert that inappropriately apparently.


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## Aidey (Jan 17, 2013)

How long before your arrival did the pt fall?


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## Aidey (Jan 17, 2013)

Christopher said:


> This right here was your answer! A ranging heart rate + tachycardia narrows it down greatly.
> 
> You know:
> (1) it is automatic not reentry (excluding the very rare possibility of flutter w/ variable conduction, but that should be obvious)
> ...




Why do you say flutter with a variable conduction ratio is a rare possibility? 

People like to cardiovert anything over 150 bpm.


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## Christopher (Jan 17, 2013)

Aidey said:


> Why do you say flutter with a variable conduction ratio is a rare possibility?
> 
> People like to cardiovert anything over 150 bpm.



Rare that it would range with an effective rate between 150-170.


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## Aidey (Jan 17, 2013)

Christopher said:


> Rare that it would range with an effective rate between 150-170.




Ahhh, right. Because it would require primarily a 2:1 conduction with occasional 1:1 beats to elevate it over 150. Even more 1:1 beats if there are any 3:1 beats in there.


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## Hunter (Jan 17, 2013)

Aidey said:


> How long before your arrival did the pt fall?


 
about 2-3 hours before we got there.


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## Aidey (Jan 17, 2013)

So the poor oral intake preceded the fall. She wasn't not eating or drinking because she was on the floor. Was she able to provide a reason she hadn't been consuming anything?


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## Hunter (Jan 17, 2013)

Aidey said:


> So the poor oral intake preceded the fall. She wasn't not eating or drinking because she was on the floor. Was she able to provide a reason she hadn't been consuming anything?


 
too weak to go to the bathroom, so she didn't wanna eat anything so she wouldn't have to.


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## mycrofft (Jan 18, 2013)

Hunter said:


> too weak to go to the bathroom, so she didn't wanna eat anything so she wouldn't have to.



Chronic and worsening cardiac trouble can do that towards the end. End of the slide.


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## Uclabruin103 (Jan 18, 2013)

Into just my third week of medic school, so be gentle.  What were her skin signs?  I'd go towards the lines of shock due to the dehydration.  She's tachycardic with a low BP, I'd address that first with a fluid challenge and maybe a vasoconstrictor then see if that helped with the HR.  If not....  We haven't gotten to that yet!


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## Handsome Robb (Jan 18, 2013)

Rykielz said:


> As I said cardioverting was unlikely to work. Adenosine even more so. But I work in California, which is a mother-may-I system and on that call they'd tell me to cardiovert if the fluid didn't work. Not my choice it's how my protocols are written. When I originally wrote that I did not know that the fluid had worked. Which is why the other treatments were listed. Assuming the  fluid didn't work that would've been the only option left other than continuing to pump her full of fluid.
> 
> Are you telling me that generalized weakness can not be a stroke? Not every stroke presents the same. Is it an unlikely diagnosis? Yes. Does it mean you can rule it out? Absolutely not. You cannot get tunnel vision on any call because the one time you do that'll be your license.



The way you worded it indicated you were jumping straight to it. "Cardioversion with versed for sedation is a better option"

No it's not. Correct the underlying problem and you fix the numbers that you're so focused on. 

Generalized weakness can be a stroke but there's nothing about the presentation of this patient that indicates a CVA to me. Generalized weakness with a fall is her only complaint. Could it be. CVA? Sure! Does her weakness have something to do with her hypovolemia? That'd be my first guess. Not a CVA. 

No one is taking your license for tunnel visioning on a call. They potentially could for performing an unsafe procedure, like cardioverting someone when it's not indicated and potentially contraindicated... 

I highly doubt you'd get into trouble for not continuing to the bottom of your narrow complex tachycardia protocol with this patient. It's a volume problem, not a cardiogenic one. Treatments focusing on cardiac etiology of the tachycardia are not going to do her any good and potentially could harm her.

My protocol says I have to is not a good answer. I'm not advocating to violate your protocols at all. All I'm trying to say is they give you permission to treat up to that's level, below it is acceptable. Patients don't fit in pretty little cookbooks.


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## Melclin (Jan 22, 2013)

But she fell....FULL SPINAL!

Not to divert the conversation but on the topic of O2 (RE someone saying something about it being unnecessary or bad), I don't think its unreasonable to shotgun some O2 while you're sorting this chickadee out. 

I'm not saying it will do any good, that it should stay on for the entire transport, nor am I saying that it absolutely should have been done. I do however think, in the first few minutes when you know little more than hypotension, tachycardia and (now I'm making things up) they look big sick and are maybe pre-arrest, its not unreasonable to apply a reasonably high concentration O2 while the rest of the picture comes to light, you have a reliable SpO2 and the rest of your work is done.

I think we here at EMT life get a little obsessed with bemoaning the whole "15lpm for everyone" BS. There isn't a lot of definitive evidence either way on this issue as far as I'm aware, and recommendations still suggest the use of high concentration O2 initially in critical illness until things calm down enough to titrate to a gas or SpO2 of choice. Now you could argue about whether or not this is "critical illness" and it probably isn't, but I still reckon there are worse things that could happen to this chick than 8 mins of O2. 

As always, happy to be proven wrong.


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## Hunter (Jan 22, 2013)

Melclin said:


> But she fell....FULL SPINAL!
> 
> Not to divert the conversation but on the topic of O2 (RE someone saying something about it being unnecessary or bad), I don't think its unreasonable to shotgun some O2 while you're sorting this chickadee out.
> 
> ...


 

Actually we had a meeting with our  new medical director that just took over about a month ago about this recently, he showed up pictures of coronary arteries of an otherwise healthy person on room air and on high concentrations of O2. The people with O2 had much more limited blood flow to the heart, it was actually scary what the difference was. The people with high flow O2 looked like they had a partial occlusion of the vessels. Also instructed us to not place patients on O2 unless they have a SaO2 of 90% or less, and that our target should be 94%.


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## alabamatriathlete (Jan 22, 2013)

Guys - lets not over-think this. Fluid challenge for BP and HR (obviously heading towards a state of shock), following getting a bit more Hx from her (which yall did, finding out pt had not eaten and drank in well over the normal time period most of us humans who like to live do in) - found out she is malnourished, dehydrated, etc. Bingo :excl:

Questions I would want to ask, like some of yall have before: how long has this weakness been going on for, why haven't you been eating or drinking, other than weakness - what else is going on (i.e. other symptoms), find out about her home life (God knows - maybe abuse or neglect is the cause, not that anything is leading me to it, but part of Hx so whatever), etc. 

How about a BGL? Diabetic maybe? Guessing that is way low too since no food or water. Obviously 12-lead will probably show small or no T's because she has been having odd BM so electrolytes are low - again, find out what is going on with that (color, normal, watery, for how long, past med/surg Hx). 

As for the debate on SVT, A-fib/flutter, PSVT, borderline tach/SVT - start simple. If she's A/Ox3, vagal (although I'd be caution bc she has already shown she has limited control over BM), meds, cardio. Sure the S/S look like you might want to shock the chick, but like Hunter said (and a lot of yall) - more of a simple fluid/malnutrition/dehydration problem. 

Possibly more underlying causes, but start simple and work advance. 

My .2 cents


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## Melclin (Jan 31, 2013)

Hunter said:


> Actually we had a meeting with our  new medical director that just took over about a month ago about this recently, he showed up pictures of coronary arteries of an otherwise healthy person on room air and on high concentrations of O2. The people with O2 had much more limited blood flow to the heart, it was actually scary what the difference was. The people with high flow O2 looked like they had a partial occlusion of the vessels. Also instructed us to not place patients on O2 unless they have a SaO2 of 90% or less, and that our target should be 94%.



That may be so, and it is roughly consistent with my understand as well, but it doesn't, in itself, really constitute _compelling_ evidence against O2. The peak body recommendations are what they are and I'm sure the British thoracic society considered those 'pictures' along with many others when they suggested empirical high concentration O2 in 'critical illness'. It has to be said, arrythmias are not usually listed in that category but the evidence doesn't really strongly point one way or the other as far as I'm aware. If you were to place this pt on O2 for 5-10 mins while you sorted everything else out, paying particular attention to the presence of critical illness that may require O2 and especially the reliability of the oximetry, then you titrated the O2 to a more reasonable level, you would probably not be sent to hell for being a terrible clinician is all I'm saying.


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## Veneficus (Jan 31, 2013)

Melclin said:


> That may be so, and it is roughly consistent with my understand as well, but it doesn't, in itself, really constitute _compelling_ evidence against O2. The peak body recommendations are what they are and I'm sure the British thoracic society considered those 'pictures' along with many others when they suggested empirical high concentration O2 in 'critical illness'. It has to be said, arrythmias are not usually listed in that category but the evidence doesn't really strongly point one way or the other as far as I'm aware. If you were to place this pt on O2 for 5-10 mins while you sorted everything else out, paying particular attention to the presence of critical illness that may require O2 and especially the reliability of the oximetry, then you titrated the O2 to a more reasonable level, you would probably not be sent to hell for being a terrible clinician is all I'm saying.



In response to this and your earlier post regarding high concentration o2.

Many of the guidlines have not changed for reasons other than the preponderance of evidence.

Not least of which is tradition and many providers who no matter what or how much evidence you present have the mental fortitude to admit prior recommendations were ineffective or wrong. 

The EBM justification to this is usually to say the studies were small or "inconclusive." One of my favorites is "there is no harm in the short term." 

Because it is saying just because in the short term there is subclinical harm while I have the patient, I don't really care what the subsequent patient condition may be. 

It is based on a long outdated concept of acute disease. 

Major society recommendations are consensus. Consensus does not make something correct. It does mean a compromise everyone can live with has been reached. 

30 years ago if you stood up and said "backboards cause harm, do no good, and I am not using it. " You would have been sent to hell as a terrible clinician. You would not be following the "expert society guidlines."  You would be no less wrong. 

Once you get over the ineffective "emergency save lives now!" mentality and start looking down the trail a bit, you start to realize that some of those emergency now treatments reduce quality and quantitiy of life a decade or more later. 

Quite a price to pay to make yourself feel like you are doing something while you figure out what is going on in my opinion.

What I think makes that morally unacceptable is you are performing that treatment not for the patient, but for yourself. 

We don't advocate giving Epi to every cardiac arrest patient because it has no short term harm and might do something. That very treatment dates back to the 1600s.

Considering the length of time that was part of consensus and that fact the AHA despite no study showing benefit in 40 years still uses it despite other society recommendations to stop using it should severely limit your respect for "consensus guidlines."

P.S. this is collective "you" not directed at Melclin personally.


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## Melclin (Jan 31, 2013)

Veneficus said:


> In response to this and your earlier post regarding high concentration o2.
> 
> Many of the guidlines have not changed for reasons other than the preponderance of evidence.
> 
> ...



I agree with most of what you're saying generally and in principle, but I feel it misses the point I was actually trying to make. I'll try to explain myself a little better. 

For the record, I don't actually agree with putting O2 on this pt. 

My point though was that I've noticed that people here have a tendency to overreact a little when they think they smell blind adherence to old school EMS doctrine. Rage, rage, rage about how absurd they think that idea/treatment to be. I think often the severity of the negative reaction has more to do with anger about the perceived adherence to an archaic status quo, than anything to do with EBM. 

Take O2 admin for example. When people see a person say, "I put X amount of O2 on a pt whose SpO2 was Y", there is usually a pretty steady stream of people saying how stupid it is to do that (lets be honest, sometimes it is, but we're not talking about those times) and I'm sure you'd agree some of those discussion have become pretty heated. Judging by the strength of the reaction, you'd think there must be an overwhelming body of evidence showing just how awful it is to do such a thing. But there isn't. In fact, I'd say in an odd sort of way that reaction might even be to do with our own little quasi-expert opinion consensus we've developed within the community of EMT-Life; an opinion just as keen at rejecting O2 as others might be at keeping it. 

I happen to agree with that opinion. I was simply warning against exactly what you are talking about. About the band wagon being hard to turn around once it gains a little momentum. 

Most of all my point was simply this: While I dont think the application of O2 in this circumstance was _right_, I also don't think its correct to call it _wrong_, given the current state of the evidence base and the recommendations that exist (whatever one may say about the peak bodies, their recommendations have to be respected to a degree. We can't all be experts in all fields enough to throw out the guidelines of many often respected and experienced experts in each field).


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## Veneficus (Jan 31, 2013)

I think we mostly agree on all the principles, we are just not communicating in an optimal way.

I was not speaking about the use of O2 in this case at all. 

I will admit that I am a bit zealous about doing things based on "wrote protocol."

This comes not from just my US experience, but my world wide medical experience of watching patient slip through the cracks of guidline based medicine. 

I think it originates from a flawed thinkng. That idea is that if you are following the rules you must be doing the right thing for the patient regardless of the need or outcome.

Now while that kind of thinking is not unique to US EMS, because of US EMS history and integration with the US fire service, which is very strongly paramilitary, it becomes very difficult to change that style of thinking. The most effective means is to consistently and adamantely take issue with it.



Melclin said:


> you'd think there must be an overwhelming body of evidence showing just how awful it is to do such a thing. But there isn't. In fact, I'd say in an odd sort of way that reaction might even be to do with our own little quasi-expert opinion consensus we've developed within the community of EMT-Life; an opinion just as keen at rejecting O2 as others might be at keeping it.



I agree this is definately the case. But I am not sure it makes it wrong. 

There are multiple podcasts and blogs by various experts on a variety of EMS and critical care issues that advocate their points and do not readily accept counter points and in some notable cases do not even acknowledge them.

On the specific matter of O2, I would say there is very appreciable evidence when you look at all of the different medical specialties that have dealt with this topic showing that emergent use of high flow O2 is not a reasonable treatment.

I would offer yet again, the Emergency Medicine community asa world-wide whole, no matter the specialty involved focuses only on all or nothing studies that are only done in the emergency environment.

I strongly feel this is a deletorious approach, not one demonstrating of expertise. Many emergency treatments and patients cannot be studies. A hyperbolic example is CPR. We cannot have a control group of those who will not have CPR performed on them. But in more reasonable research, it is aways difficult for a variety of reasons. That limits the very ability to gather research. To then turn around and say there isn't "a lot," or "definitive" evidence while failing to acknowledge or extrapolate studies and evidence from other specialties is not simply disingenious, it is entirely self serving.



Melclin said:


> but I doubt that the British Thoracic society sat around giggling about it being 'the doc's problem', while they cleaned their rigs and went on the next call



I doubt they did that too. But I do not think it is outrageous to think that sat around and said "these decisions are too complex to put in the hands of EMS providers so we will create our guideline on the side of administering treatment as opposed to withholding it." 



Melclin said:


> given the current state of the evidence base and the recommendations that exist (whatever one may say about the peak bodies, their recommendations have to be respected to a degree. We can't all be experts in all fields enough to throw out the guidelines of many often respected and experienced experts in each field).



While I agree with this, and personally defer to guidelines when I am not in the know, I have also been burned by following those guidelines in certain cases to the detriment of the patient.

The question then becomes not "should we follow the guidelines" but "how do we interpret and integrate these guidlines in practice?"


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## Hunter (Jan 31, 2013)

Veneficus said:


> The question then becomes not "should we follow the guidelines" but "how do we interpret and integrate these guidlines in practice?"



Better way to put it I think... Or maybe not better but easier for the people who swear by protocols, "which ones do we follow based on evidence and presentation, and which parts apply to THIS patient".
By "this" I don't mean the patient that was originally discussed but whatever patient you have in front of you, no better yet whom ever you have in front of you.

And I don't think anyone here would say "Don't follow protocol!" Because that would get you fired.


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## Veneficus (Jan 31, 2013)

Hunter said:


> And I don't think anyone here would say "Don't follow protocol!" Because that would get you fired.



I know many agencies require providers to follow protocols like they are baking a cake. One step before the other, always in the same order and always all the steps.

I actually worked for one once. Briefly. We do not miss each other...

But I would say it is more common today to choose which part of the protocol you are using. Sometimes using multiple ones or parts of multiple ones. Even switching between them.

I am not suggesting not following your standing orders. Simply to be better at applying them.


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## Melclin (Feb 4, 2013)

Veneficus said:


> I think we mostly agree on all the principles, we are just not communicating in an optimal way.
> 
> *Oh well, we'll disagree about something one day, mate. We just have to keep trying  *
> 
> ...



If you happen to have a list kicking around and its easy to copy and past, have you got a set of references or resources RE detrimental effects of O2 from other specialities that I may not have read? I think its probably time I gave O2 another and more thorough look. It's been a while since I really looked at the literature on the topic.


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## Veneficus (Feb 4, 2013)

Melclin said:


> If you happen to have a list kicking around and its easy to copy and past, have you got a set of references or resources RE detrimental effects of O2 from other specialities that I may not have read? I think its probably time I gave O2 another and more thorough look. It's been a while since I really looked at the literature on the topic.



Start with Robbin's and Guytons. Since there is stuff in there about it it must be at least 5 years old.


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