# New EMT, don't understand a couple of calls.



## VirginiaEMT (May 29, 2010)

Hello,

I am new here to the forum and to being and EMT. I need some help, maybe I am just a gung-ho rookie EMT, maybe I don't understand, or maybe I'm right, but I have a couple of questions about calls I recently ran with anothe AIC.

1.What is hyperglycemia? It is my thought that it simply means an excessive blood gluose level. The patient had a D-stick of 175, he said normal is around 120. He was laying on a bench at Wal-Mart, with an altered LOC, but signed a patient refusal because he was feeling better and didn't want to go with us.

As I was questioning the AIC, who is an EMT-E, he said he wasn't hyperglycemic, that is blood sugar simply spiked because it was originally low, and when he ate it shot up. 

I thought anything above a 140, for anyone is considered hyperglycemic?

2. We ran an attempted suicide, female with incisions on both wrist. Very deep blood bleeding was almost clotted upon our arrival, but not completely.

The AIC started asking her questions about WHY she did it, and started telling her that suicide was no way out, and I'm thinking "who gives a crap, let's fix her" first. Here's the questions I have:

A. I controled bleeding on right wrist, and bandaged, no problems encountered. The left wrist was still slightly bledding, not an artery bleed, I place a dressing on it and elevated. I asked the AIC to open another 4x4 because she was bleeding through the original, and I was going to place  another one on top, and continue direct pressure. The AIC said no, that I didn't want to do that because I was "over-dressing it", she said she was told by our OMD, to simply leave the original, and push down on the bleed harder, with the thumb. Again. this was venous bleeding. What do you feel is the right answer.

B. The ladies color was still o.k, but her pupils were dialated and very slow(she said she had not taken any drugs). I mentioned that we should put her on 15LPM of O2 with a NRB, number one because of the loss of blood, and her pupils reaction to light as well as being dialated, and she said that the patient wasn't shocky and a nasal with 6LPM would be sufficient.I drove to the hospital, and when we entered the ER, she had completely taken the O2 off. I am under the opinion we should have treated for shock, because it could have only helped, and not hurt her in any way.

Any thoughts????


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## Aidey (May 29, 2010)

VirginiaEMT said:


> Hello,
> 
> I am new here to the forum and to being and EMT. I need some help, maybe I am just a gung-ho rookie EMT, maybe I don't understand, or maybe I'm right, but I have a couple of questions about calls I recently ran with anothe AIC.
> 
> ...



There is a difference between a clinically significant number and an elevated but relatively insignificant number. A totally healthy person could hit 175mg/dl by eating a large meal with a lot of carbs in it. I have a hard time thinking of a situation where a chem of 175mg/dl would concern me. 




VirginiaEMT said:


> 2. We ran an attempted suicide, female with incisions on both wrist. Very deep blood bleeding was almost clotted upon our arrival, but not completely.
> 
> The AIC started asking her questions about WHY she did it, and started telling her that suicide was no way out, and I'm thinking "who gives a crap, let's fix her" first. Here's the questions I have:
> 
> ...



I'm not sure what your medic meant by overdressing. The only thing I can think of is that adding more gauze doesn't really help if you aren't applying any pressure. 

As for the O2 this patient likely didn't need any oxygen. Dilated pupils is not enough reason to put someone on O2. Was she tachy? Hypotensive? Breathing fast? The pts pupils were likely dilated from an activation of her flight or fight response due to the high emotions of the situation. 

If her vital signs were within acceptable limits I highly doubt she was in shock. Doing things "just because it won't hurt" isn't a good idea. If the pt wasn't in shock, she didn't need to be treated for shock. 

Generally patients must pass the "blue test" to get 15lpm via NRB, ie, they must be blue in order to get it. There are some exemptions to this, but for the most part unless a patient is blue they get a cannula first (that is if oxygen is indicated at all).


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## johnrsemt (May 29, 2010)

*fix her first*

It doesn't hurt to talk to the patient while you are stopping the bleeding and dressing the wounds;
  In fact the more you talk to them the better.  let them know what you are doing:  makes  the patient more comfortable and helps them to relax.  helps them the think that maybe you know what you are doing.

   I have had patients that the only thing I did for them on the run is hold their hand, and talk to them


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## Fox (May 29, 2010)

VirginiaEMT said:


> Hello,
> 
> I am new here to the forum and to being and EMT. I need some help, maybe I am just a gung-ho rookie EMT, maybe I don't understand, or maybe I'm right, but I have a couple of questions about calls I recently ran with anothe AIC.
> 
> ...



In class they teach you to give EVERYONE a NRB at 15LPM. In fact, if we didn't do it every check off we failed.

But look at it this way. If a patient only needed 5mg of medicine to feel better, would you give them 15mg? No. O2 is considered a drug, so give it as the patient can tolerate and use it when it's needed, not overkill.  Sometimes a NC is more appropriate for the situation.

That's just how I view it. 

As for the dressing, I really couldn't tell you. That seems weird to me. If you were using pressure and she bled through, the I would've added another dressing.

I've had a PCP tell me to not worry about blood sugar til it hit 180-200. I think it depends on the patient and the activities that led to the sugar spike. And the doctor.


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## TransportJockey (May 29, 2010)

About the diabetic call:
I've had a few patients that were frequent fliers that a 'low' CBG was in the 200's, they normally stayed at 3-400. Not everyone is text book for 'normal vitals'


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## medic417 (May 29, 2010)

jtpaintball70 said:


> About the diabetic call:
> I've had a few patients that were frequent fliers that a 'low' CBG was in the 200's, they normally stayed at 3-400. Not everyone is text book for 'normal vitals'



Exactly.  Treat the patient not the text book.  Many patients with medical problems know what the normal vitals for them are.  Listen to them.  If you are in a good system you can provide care based on patient norms not some numbers in a protocol book.  If you are in a bad system that requires everything match the protocol numbers then you may need to call medical control and ask to treat the patient based on their norms, which will probably be denied because any system that requires call med control is garbage.


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## VirginiaEMT (May 29, 2010)

johnrsemt said:


> It doesn't hurt to talk to the patient while you are stopping the bleeding and dressing the wounds;
> In fact the more you talk to them the better.  let them know what you are doing:  makes  the patient more comfortable and helps them to relax.  helps them the think that maybe you know what you are doing.
> 
> I have had patients that the only thing I did for them on the run is hold their hand, and talk to them



We weren't doing any interventions, simply asking questions at that point. I am very glad to see that I can actually get answers to questions I may have, on this forum. I really appreciate it.


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## medic417 (May 29, 2010)

VirginiaEMT said:


> We weren't doing any interventions, simply asking questions at that point.



What you will learn is often one person will be talking to the patient while the other starts treatment.  Your partner probably thought you would start bandaging the wounds while they calmed the patient.


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## VirginiaEMT (May 29, 2010)

medic417 said:


> What you will learn is often one person will be talking to the patient while the other starts treatment.  Your partner probably thought you would start bandaging the wounds while they calmed the patient.



You're probably right. I did well in my EMT-B class, 96 average, and passed the state exam with a 90, I guess now it's time to get into the real world and learn street smarts.


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## CSLEMT (May 29, 2010)

*EMT Question...  What Would You Do?*

Recently watched a Little League baseball game when a batter was hit by a fastball on the left ear side of helmet.

Batter immediately dropped...  he remained conscious.  

Players coach waved off people on field as he approached the batter and attended to player.

As an EMT, what would you do?


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## Akulahawk (May 29, 2010)

CSLEMT said:


> Recently watched a Little League baseball game when a batter was hit by a fastball on the left ear side of helmet.
> 
> Batter immediately dropped...  he remained conscious.
> 
> ...



In my case, I'd want to know what role I'm in... Why? Simple. Some roles I can fill will limit what my response would be for our fallen batter.

In an EMT role, once you're called onto the field, your options are quite limited. You're going to basically start running the Head Injury/C-Spine protocol and that batter will likely end up being transported to the ED on a LSB. As a Paramedic, your options might improve a bit if you're trained and authorized to clear C-Spine in the field. Otherwise, the Paramedic will have to follow the same basic C-Spine script the EMT follows.

An ATC has more options than that... but you're not going to be using those options if you're working as an EMT or Paramedic.


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## clibb (May 29, 2010)

Hyper means excessive. So yeah, high blood sugar. 175 isn't scary high. 80-120 is the normal range for a non-diabetic adult.

I had a patient that was on a insulin pump and was DKA and her blood sugar was 477. She was NOT feeling good. 

With the oxygen, that totally depends on your protocol. Where I did my ride-alongs, you had to put oxygen on nearly every patient. It was more of a courtesy then anything else. 
Do happen to know what her SP02 was at? That should be what  you would determine if the patient needed oxygen or not.


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## medichopeful (May 29, 2010)

Aidey said:


> The pts pupils were likely dilated from an activation of her flight or fight response due to the high emotions of the situation.



Dilated pupils can also be caused by loss of blood (hypovolemia).


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## JPINFV (May 29, 2010)

CSLEMT said:


> As an EMT, what would you do?



Depends on the assessment and level of play. Sorry, but being hit in the helmet by a 10 year old throwing a fast ball doesn't concern me.


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## usafmedic45 (May 29, 2010)

> she said she had not taken any drugs





> Any thoughts????



Other than she was probably lying?  Especially given that most suicides have something on board, even if not in toxic or lethal dosages.



> 175 isn't scary high



Unless it is <100 or >400 I don't get concerned in the field.



> Recently watched a Little League baseball game when a batter was hit by a fastball on the left ear side of helmet.
> 
> Batter immediately dropped... he remained conscious.
> 
> ...



Off duty?  Absolutely nothing. 



> a nasal with 6LPM would be sufficient.I drove to the hospital, and when we entered the ER, she had completely taken the O2 off. I am under the opinion we should have treated for shock, because it could have only helped, and not hurt her in any way.



Actually a nasal cannula at 2 LPM would be my only consideration, if I gave O2 at all. Not giving O2 in this situation would not have set off any alarm bells in my book and I used to do chart review for several EMS systems. 

BTW, we don't do things because they "aren't going to hurt", or at least we shouldn't be.  We should only do things that are going to help.  It's called evidence-based practice and it is worth learning, looking into and being proactive in regards to when it comes to EMS protocol development. 



> Dilated pupils can also be caused by loss of blood


So far as I am aware, that only happens in massive, uncontrolled shock.  Do you have a citation for it occurring otherwise?


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## VirginiaEMT (May 29, 2010)

CSLEMT said:


> Recently watched a Little League baseball game when a batter was hit by a fastball on the left ear side of helmet.
> 
> Batter immediately dropped...  he remained conscious.
> 
> ...



I guess this is directed at me. First, since I saw what happened that would eliminated the need to ask what happened.

Tell the coach who I am and my qualifications. call for EMS
1.have someone maintain c-spine
2.then I would check AVPU. 
3.I would check to see if his airway was compromized due to blood, teeth.If so, if so, carefully log roll(recovery position), to allow for drainage so the airway is maintained. 
4.I would also apply ice to the damaged area to reduce swelling
5. maintain airway and be prepared for changes until EMS arrives, also maintain conversation with the boy
6. I would watch his pupils for changes, check any vitals I can without equipment, skin color, watch for symptoms of shock, and gather as much info as I can SAMPLE,OPQRST,ETC. for the EMS personnel.

This is assuming I am just sitting there with no ambulance or equipment. I have a small first aid bag, with general equipment. Still working on it. If you want my treatment with an ambulance handy, I do that too.


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## JPINFV (May 29, 2010)

VirginiaEMT said:


> 2. We ran an attempted suicide, female with incisions on both wrist. Very deep blood bleeding was almost clotted upon our arrival, but not completely.
> 
> The AIC started asking her questions about WHY she did it, and started telling her that suicide was no way out, and I'm thinking "who gives a crap, let's fix her" first.


While I question the ability of EMS providers to provide proper counseling, fixing the psych issues is just as much fixing the patient as wrapping the wrists.  



> B. The ladies color was still o.k, but her pupils were dialated and very slow(she said she had not taken any drugs). I mentioned that we should put her on 15LPM of O2 with a NRB, number one because of the loss of blood, and her pupils reaction to light as well as being dialated, and she said that the patient wasn't shocky and a nasal with 6LPM would be sufficient.I drove to the hospital, and when we entered the ER, she had completely taken the O2 off. I am under the opinion we should have treated for shock, because it could have only helped, and not hurt her in any way.
> 
> Any thoughts????



Research the oxygen content equation.


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## JPINFV (May 29, 2010)

Here's something to chew on for the new EMTs. 

Which is worse, taking a baseball to the head or taking a baseball to the chest?


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## adamjh3 (May 29, 2010)

It depends on the force behind the ball, where on the body part the victim was hit, and the protective gear the victim is wearing.

Because a fast ball thrown by Randy Johnson that pegs you in the head with no helmet on could certainly cause some sort of brain injury - if not a skull Fx. - depending upon where it hits. 

And that same fast ball hits you in the thorax, it could probably break ribs, no?


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## TransportJockey (May 29, 2010)

JPINFV said:


> Here's something to chew on for the new EMTs.
> 
> Which is worse, taking a baseball to the head or taking a baseball to the chest?



Can I answer? I know this one


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## Lifeguards For Life (May 29, 2010)

adamjh3 said:


> And that same fast ball hits you in the thorax, it could probably break ribs, no?



commotio cordis


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## TransportJockey (May 29, 2010)

Lifeguards For Life said:


> commotio cordis



bingo!


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## Lifeguards For Life (May 29, 2010)

jtpaintball70 said:


> bingo!



that was meant to be a hint, as i assumed he would have to look it up


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## TransportJockey (May 29, 2010)

Lifeguards For Life said:


> that was meant to be a hint, as i assumed he would have to look it up



He probably still will, cause most basics I know have no idea what that is


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## JPINFV (May 29, 2010)

adamjh3 said:


> It depends on the force behind the ball, where on the body part the victim was hit, and the protective gear the victim is wearing.
> 
> Because a fast ball thrown by Randy Johnson that pegs you in the head with no helmet on could certainly cause some sort of brain injury - if not a skull Fx. - depending upon where it hits.
> 
> And that same fast ball hits you in the thorax, it could probably break ribs, no?



Assume proper match up (i.e. Randy Johnson isn't facing a 12 year old) and proper safety equipment (i.e. batting helmet).


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## adamjh3 (May 29, 2010)

Hm... I had considered something along those lines, but discounted it thinking the sternum was stout enough to protect the heart. Interesting, less than one in five that experience Commotio Cordis survive. 

But as to it being "worse" it would depend on when in the cardiac rythym the victim was struck. There's a very small window for Commotio Cordis to occur. So being struck in the head can still be "worse."


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## 8jimi8 (May 29, 2010)

Aidey said:


> *Generally patients must pass the "blue test" to get 15lpm via NRB*, ie, they must be blue in order to get it. There are some exemptions to this, but for the most part unless a patient is blue they get a cannula first (that is if oxygen is indicated at all).



I will chime in only to disagree with this statement.

Please do not teach new emt's that patient's have to be blue before they get an NRB w/15 l/min.

If you are going to talk about treatments, please list the reasons why you would/n't, not strange generalizations that are not 100% true.


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## medichopeful (May 29, 2010)

usafmedic45 said:


> So far as I am aware, that only happens in massive, uncontrolled shock.  Do you have a citation for it occurring otherwise?



I was a little unclear.  This would be due to shock, not just blood loss:



> "Other signs of shock that you may encounter include thirst, dilated pupils, and in some cases cyanosis around the lips and nail beds" (Limmer and O'Keefe, "Emergency Care 11th Edition", page 620).





> Symptoms may include:
> 
> Weakness
> Altered mental status
> ...



Unless I'm reading it wrong, it doesn't have to be "massive shock" for dilated pupils to occur.  But if I'm wrong, please correct me.  You have more education, and I might be able to learn something*

*Reading this, it sounds sarcastic but it isn't meant to be


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## usafmedic45 (May 29, 2010)

> Unless I'm reading it wrong, it doesn't have to be "massive shock" for dilated pupils to occur. But if I'm wrong, please correct me. You have more education, and I might be able to learn something



You normally only see it (at least in my experience) in patients where perfusion to the brain is being impeded somehow.  This is why a person's pupils will dilate just before they pass out from being put in a choke hold.  Given that the heart and the brain are the last organs to be perfused, you normally have to get a pretty major hit going on before you are going to get to that point.  Given that in most people (short of persons with clotting disorders (hemophilia, VWD, etc) or on potent anticoagulants, it is exceedingly rare* to bleed to death from an isolated vascular injury below the knee or elbow I would seriously doubt she was in shock.  

*Sufficiently rare that I would actually write it up as a case report for publication. 



> Reading this, it sounds sarcastic but it isn't meant to be



No worries even if it was meant to be sarcastic.   You're going to learn whether you like it or not.  



> Which is worse, taking a baseball to the head or taking a baseball to the chest?



I'd take my chances with the baseball to the chest before a baseball to the head.  The incident of _commotio cordis_ is really quite low, especially in comparison to the much greater risk of a skull fracture, intracranial bleed or concussion from a direct shot to the head. 



> But as to it being "worse" it would depend on when in the cardiac rythym the victim was struck. There's a very small window for Commotio Cordis to occur. So being struck in the head can still be "worse."



What he said.



> Randy Johnson isn't facing a 12 year old



Have you seen the pitching ability of some of the minor leaguers these days? Dear God...



> Because a fast ball thrown by Randy Johnson that pegs you in the head with no helmet on could certainly cause some sort of brain injury - if not a skull Fx. - depending upon where it hits.



I'm pretty sure if it did not cause a skull fracture, he'd be getting his contract renegotiated because obviously he's slacking off.


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## lightsandsirens5 (May 29, 2010)

jtpaintball70 said:


> About the diabetic call:
> I've had a few patients that were frequent fliers that a 'low' CBG was in the 200's, they normally stayed at 3-400. Not everyone is text book for 'normal vitals'


 
Yet another reson I hate the current textbooks........and the "Within Normal Limits" moniker or whatever you call those things


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## TransportJockey (May 29, 2010)

lightsandsirens5 said:


> Yet another reson I hate the current textbooks........and the "Within Normal Limits" moniker or whatever you call those things



Ya know what else WNL stands for don't ya?


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## adamjh3 (May 29, 2010)

usafmedic45 said:


> I'm pretty sure if it did not cause a skull fracture, he'd be getting his contract renegotiated because obviously he's slacking off.



Touche`, I'm still new to learning MOI's and what not, I wasn't positive if it would or not, so I didn't want to make a general sweeping statement and make myself look a fool. 

I'm not much of a baseball fan anyway h34r:


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## LucidResq (May 29, 2010)

Oh boy oh boy oh boy.... sudden cardiac death in young athletes is my favorite. I have written quite a few papers on it.... though usually focused on intrinsic causes. 

Commotio cordis is extremely rare, and like Adam stated, one must be hit in a specific 10-30 millisecond long segment of the cardiac cycle, in the right spot as well. Postmortem exam usually reveals no internal trauma or hemorrhage... occasionally a little bruising but nothing that would normally be fatal or even problematic. It truly is an electrical phenomenon. 

Research has been done on chest protectors commonly used in sports but they do little to nothing to guard against commotio cordis. 

Resuscitation is futile, especially considering how most victims are healthy and young.


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## usafmedic45 (May 29, 2010)

> I'm still new to learning MOI's and what not, so I wasn't positive if it would or not, so I didn't want to make a general sweeping statement and make myself look a fool



MOIs are pretty much my area of expertise anymore.  The general rule is that the human skull is like most Marines in a barfight.  It's tough, but not as tough as a lot of people like to believe.


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## LucidResq (May 29, 2010)

As for the discussion of force.... bear in mind that force has little to do with commotio cordis. It happens most with young athletes, so the kid pitching or what not is probably not throwing that hard. 

I agree with USAF too.... I'd rather take the very small risk of commotio cordis and get hit in the chest. Even if you did fall victim to it, it'd be a quick and painless way to go. Head injuries scare me much more than death.


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## adamjh3 (May 29, 2010)

usafmedic45 said:


> MOIs are pretty much my area of expertise anymore.  The general rule is that the human skull is like most Marines in a barfight.  It's tough, but not as tough as a lot of people like to believe.



I showed that to my brother (Ex-Army 75th ID) and he's about in tears right now.


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## usafmedic45 (May 29, 2010)

> Resuscitation is futile, especially considering how most victims are healthy and young.



I like you, but you're being hyperbolic.  I wouldn't call it "futile", not even close to it.  The survival rate is still better than most cardiac arrest events, even better than many in-hospital non-ICU resuscitation rates. 


> The overall survival rate in known victims of CC is only 15% [1]





> Of 68 cases in which early resuscitation was instituted (< 3 minutes), 17 survived (25%). In the cases where resuscitation was substantially delayed (> 3 minutes) only 1 out of 38 survived (3%).



The problem then is obviously not the mechanism (as you are implying, intentionally or otherwise), it's a failure to have timely access to an AED.  This is why if someone on this forum wants to make a difference in their community in terms of patient outcomes, assuring that every organized sporting event has ready (<3 minutes) access to an AED would be a great project. 


[1]Madias C, Maron BJ, Alsheikh-Ali AA, Estes Iii NA, Link MS.  Commotio cordis.  Indian Pacing Electrophysiol J. 2007 Oct 22;7(4):235-45.


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## usafmedic45 (May 29, 2010)

From the same article I just cited....emphasis is my own.



> Since being initiated in 1996, the United States Commotio Cordis Registry (USCCR - Minneapolis, Minnesota) has now accrued more than 180 cases [3-5]. As awareness of this phenomenon grows, CC is being reported with increasing frequency, with most cases in the registry (75%) clustered from the years 1988 to present [6]. However, the actual incidence remains unknown as many cases are still likely missed due to continued lack of recognition and underreporting. CC has most commonly been described in the setting of organized sport (Table 1), with most victims having been struck in the chest by standard projectiles used in the game [3]. *Generally, projectiles that result in CC have a dense solid core, such as a baseball, hockey puck, or lacrosse ball.* Only 2 cases in the USCCR have been attributed to impact with a cricket ball. However, this low incidence likely reflects the relative lack of popularity of cricket in the US and the fact that chest impact in cricket is a rare event. *Projectiles with a non-solid core tend to collapse on contact and absorb much of the impact energy. Only a single event has been attributed to chest impact with an air-filled soccer ball.* In almost all cases, chest impacts that resulted in CC occurred to the left of the sternum, directly over the cardiac silhouette. *Estimated velocities of pitched baseballs were 48 to 80 km/h (30-50 mph).* Interestingly, 38% of the individuals competing in organized sports were wearing standard commercially available chest wall protection at the time of their event [7]. However, in 25 of these 32 cases, the chest wall protector did not adequately cover the left chest or precordium at the time of impact.



The force- rather than the velocity, don't confuse the two which are related but not the same thing- does play a role.  It's the dissipation and transfer of that force that matters.  The reason a solid baseball (about 145 grams and roughly three inches in diameter) is going to impart more force through the chest wall (measured in joules/square inch) at the same speed than say, a 29" and 600 gram basketball.


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## VirginiaEMT (May 29, 2010)

JPINFV said:


> Here's something to chew on for the new EMTs.
> 
> Which is worse, taking a baseball to the head or taking a baseball to the chest?




I would think the would depend on the age of the person as a younger child's ribs would be more flexible, and although internal injuries would be possible, a flail chest is far less likely to happen causing more serious internal injuries.


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## usafmedic45 (May 29, 2010)

> I would think the would depend on the age of the person as a younger child's ribs would be more flexible, and although internal injuries would be possible, a flail chest is far less likely to happen causes more serious internal injuries.



This is also an issue.  Nice point.  Well done newb.


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## VirginiaEMT (May 29, 2010)

medichopeful said:


> Dilated pupils can also be caused by loss of blood (hypovolemia).



This is my point, wouldn't this be a reason for the high flowo2. It would have been my guess that because of the blood loss, we should have given high flow o2 to prevent her from becoming shocky instead of waiting for her to get shocky.


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## JPINFV (May 29, 2010)

LucidResq said:


> As for the discussion of force.... bear in mind that force has little to do with commotio cordis. It happens most with young athletes, so the kid pitching or what not is probably not throwing that hard.
> 
> I agree with USAF too.... I'd rather take the very small risk of commotio cordis and get hit in the chest. Even if you did fall victim to it, it'd be a quick and painless way to go. Head injuries scare me much more than death.



Based off of pure observation (including playing Little League growing up), I'd say that LL'ers suffering any sort of long term damage from taking a pitch to the helmet is also extremely rare. I'd be interested in the incident rate of taking a line drive (in contrast to, say, a pop fly that would almost guarenteed to be deflected off of a glove) though. However, it seems that every few years a case of CC makes it to the news.


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## VirginiaEMT (May 29, 2010)

LucidResq said:


> Oh boy oh boy oh boy.... sudden cardiac death in young athletes is my favorite. I have written quite a few papers on it.... though usually focused on intrinsic causes.
> 
> Commotio cordis is extremely rare, and like Adam stated, one must be hit in a specific 10-30 millisecond long segment of the cardiac cycle, in the right spot as well. Postmortem exam usually reveals no internal trauma or hemorrhage... occasionally a little bruising but nothing that would normally be fatal or even problematic. It truly is an electrical phenomenon.
> 
> ...




I am not familiar with commtio cordis. However, I do have a son who is a basketball nut and is also 16 and 6'8" tall. Could you explain?


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## LucidResq (May 29, 2010)

I agree, especially with the bit on access to AEDs, however a recent study showed a 30% survival rate (to hospital discharge) of adolescents (12-19) who experienced out-of-hospital cardiac arrest in VT or VF.... of course commotio cordis is most common in adolescents, is out-of-hospital and is VF. 

Hyperbolic... maybe. And you're right about the distinction between velocity and force. My bad. 

Atkins, D. L., Everson-Stewart, S., Sears, G. K., Daya, M., Osmond, M. H., Warden, C. R., Berg, R. A., and the Resuscitation Outcomes Consortium Investigators 2009. Epidemiology and outcomes from out-of-hospital cardiac arrest in children: The Resuscitation Outcomes Consortium epistry-cardiac arrest. Circulation 119:1484-1491.


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## LucidResq (May 29, 2010)

VirginiaEMT said:


> I am not familiar with commtio cordis. However, I do have a son who is a basketball nut and is also 16 and 6'8" tall. Could you explain?



Essentially what happens in commotio cordis is a person is struck in the chest by some projectile at a very specific moment in the cardiac cycle, throwing the heart into ventricular fibrillation and cardiac arrest. The person does not die from something like blood loss or physical damage caused by the object hitting them, they die due to the interference with their heart's electrical cycle. 

It is most common in sports like baseball and lacrosse, because as USAF quoted from a study: 


> Projectiles with a non-solid core tend to collapse on contact and absorb much of the impact energy. Only a single event has been attributed to chest impact with an air-filled soccer ball.



I wouldn't be worried about it with your son playing basketball. Even if he played something like baseball, commotio cordis is extremely rare.


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## usafmedic45 (May 29, 2010)

> Even if he played something like baseball, commotio cordis is extremely rare.



The few I have heard about involved elbows or headbutts to the chest, but as you said, it is a very rare occurrence.


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## VirginiaEMT (May 29, 2010)

LucidResq said:


> Essentially what happens in commotio cordis is a person is struck in the chest by some projectile at a very specific moment in the cardiac cycle, throwing the heart into ventricular fibrillation and cardiac arrest. The person does not die from something like blood loss or physical damage caused by the object hitting them, they die due to the interference with their heart's electrical cycle.
> 
> It is most common in sports like baseball and lacrosse, because as USAF quoted from a study:
> 
> ...




Thanks.....


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## usafmedic45 (May 29, 2010)

> I agree, especially with the bit on access to AEDs, however a recent study showed a 30% survival rate (to hospital discharge) of adolescents (12-19) who experienced out-of-hospital cardiac arrest in VT or VF.... of course commotio cordis is most common in adolescents, is out-of-hospital and is VF.



From the abstract of that article: 



> Survival for all pediatric OHCA was 6.4% (3.3% for infants, 9.1% for children, and* 8.9% for adolescents*)



From another part of the article:  


> Survival to hospital discharge for *all nontraumatic pediatric OHCA was 6.4% compared with 4.5% survival for adult*





> Overall survival rate among pediatric patients who received EMS treatment was 7.8%, with 3.5% for infants, 10.4% for children, and 12.6% for adolescents.





> Importantly, this study demonstrates that commonly reported overall survival figures are heavily influenced by very poor infant survival, whereas children and adolescents have substantially greater survival compared with adults.



Where are you getting a 30% survival rate from?  The only mention I see of a statistic approaching that is an in-hospital study with 27%: 


> First, a study from the National Registry of Cardiopulmonary Resuscitation showed that the survival to hospital discharge after pulseless in-hospital cardiac arrest was higher among children (0 to 18 years) than adults (27% versus 18%), primarily because of better outcomes with a first documented rhythm of asystole/pulseless electric activity.



Also keep in mind the following:


> The ROC Epistry–Cardiac Arrest is a large, diverse observational study conducted over a short time period. However, a large database with significant heterogeneity of event identification and potential variability in data abstraction may limit validity.13 Of note, the ROC Epistry–Cardiac Arrest database *does not capture outcomes beyond hospital discharge, including neurological outcome*.



BTW, here's a link to the full article in case anyone is interested:  http://circ.ahajournals.org/cgi/content/full/119/11/1484


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## LucidResq (May 29, 2010)

Table 4.


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## lightsandsirens5 (May 29, 2010)

usafmedic45 said:


> The few I have heard about involved elbows or headbutts to the chest, but as you said, it is a very rare occurrence.


 
So why would defib not "fix" this? Isn't it just strait up VF caused by trauma?


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## Lifeguards For Life (May 29, 2010)

LucidResq said:


> Oh boy oh boy oh boy.... sudden cardiac death in young athletes is my favorite. I have written quite a few papers on it.... though usually focused on intrinsic causes.
> 
> Commotio cordis is extremely rare, and like Adam stated, one must be hit in a specific 10-30 millisecond long segment of the cardiac cycle, in the right spot as well. Postmortem exam usually reveals no internal trauma or hemorrhage... occasionally a little bruising but nothing that would normally be fatal or even problematic. It truly is an electrical phenomenon.
> 
> ...





> Statistics compiled by the US Consumer Product Safety Commission1 indicate that there were 88 baseball-related deaths to children in this age group between 1973 and 1995, an average of about 4 per year. This average has not changed since 1973. O*f these, 43% were from direct-ball impact with the chest (commotio cordis); 24% were from direct-ball contact with the head*; 15% were from impacts from bats; 10% were from direct contact with a ball impacting the neck, ears, or throat; and in 8%, the mechanism of injury was unknown


-http://aappolicy.aappublications.org/cgi/content/full/pediatrics;107/4/782

there are other studies with similar statistics


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## Lifeguards For Life (May 29, 2010)

lightsandsirens5 said:


> So why would defib not "fix" this? Isn't it just strait up VF caused by trauma?



The treatment of Commotio Cordis  is no different from any other cardiopulmonary emergency associated with asystole. 

The relatively low rate of survival from Commotio Cordis is most likely caused by the delay in instituting effective CPR measures because bystanders frequently fail to appreciate the severity of the event, lack knowledge of Commotio Cordis, or mistakenly believe that the trauma was insignificant. Many observers have commented that they" believed that the wind was knocked out of the person".

What do you guys think about the use of the precordial thump, in witnessed cases of Commotio Cordis, when a defibrillator is not available?


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## usafmedic45 (May 29, 2010)

In one subset (pts w/ VF), that does not imply that the overall survival rate is 30%.  Don't cherry pick data.  



> of course commotio cordis is most common in adolescents, is out-of-hospital and is VF.



Actually by the time EMS gets to them (which is what we are working from in the Atkins article), a significant are in asystole.  

From the Madias et al article I cited earlier:


> Analysis revealed 33 cases of VF, 3 with ventricular tachycardia, 3 with bradyarrhythmias, 2 with idioventricular rhythm, and 1 with complete heart block. Forty of the cases documented asystole, which was unlikely to be the initial rhythm after impact, and is more likely a result of prolonged time from event to rhythm documentation.



That would be:
Total of 82 cases
VF/VT- ~44%
Bradydysrhythmias- ~3.6%
Idioventricular- ~2.4%
Complete heart block- ~1.2%
Asystole-  ~49%

Don't cherry pick data.  This is a major problem in resuscitation research: you can't compare one group to another unless they are controlled for the variability.  In this case, you have to include the overall cohort (all rhythms for comparison) rather than operating off the idea that all commotio cordis cases we see (or even the majority of them) are going to be in VF, mostly due to delays in access to care.  If we were to achieve 100% access to AEDs in the first moments after a commotio cordis case occurs, chances are good that the survival rate would be very similar to what you are trying to compare it to, but unfortunately you are talking about two distinct groups.  One is very homogeneous (all VF/VT) and the other is very heterogeneous (any rhythm). 



> Isn't it just strait up VF caused by trauma?



The main problem is delay in access to defib.  It's not "trauma" technically (in the sense of tissue damage).  It's more akin to the idea behind a precordial thump.

From the Madias article:


> Similar outcomes were seen in our model of CC in which defibrillation with an automated external defibrillator (AED) within 1 or 2 minutes of VF resulted in successful resuscitation in 100% and 92% of animals, respectively [21]. Only 46% of shocks were successful after 4 minutes, and after 6 minutes survival decreased further to 25% (p<0.0001).





> This average has not changed since 1973. Of these, 43% were from direct-ball impact with the chest (commotio cordis); 24% were from direct-ball contact with the head; 15% were from impacts from bats; 10% were from direct contact with a ball impacting the neck, ears, or throat; and in 8%, the mechanism of injury was unknown


Can I point out the potential issue with looking at that data to decide which is a bigger threat?  The lethality of commotio cordis is much higher so the number is going to be much larger.  One would really need to look at injury morbidity, not mortality statistics to see which poses a greater risk.  



> What do you guys think about the use of the precordial thump, in witnessed cases of Commotio Cordis, when a defibrillator is not available?



Can't hurt, but probably won't help.  I recall an article that showed that it was actually more effective in asystole for some reason than in VF/VT.


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## Lifeguards For Life (May 29, 2010)

usafmedic45 said:


> Can't hurt, but probably won't help.  I recall an article that showed that it was actually more effective in asystole for some reason than in VF/VT.





> Originally Posted by *Guardian*
> I've heard of the precordial thump causing commotio cordis, but not proper cpr...anyone hear different?


http://emtlife.com/showthread.php?t=3677&highlight=commotio+cordis

has anyone heard of this?


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## LucidResq (May 29, 2010)

Interesting, I kind of assumed that head injury would be more prevalent. 

It's V Fib, not asystole. Initially anyways. 

Precordial thumps have caused commotio cordis... but as far as treating it... of course there are few really good clinical studies but there is little (I can't find any) evidence to support use of the precordial thump especially for V Fib.... 



> Despite generating high LV pressures, precordial thumps were not effective in terminating VF. Based on these data, precordial thump for VF in cardiac arrest victims cannot be recommended but for asystolic victims might be beneficial.



Madias, C., Maron, B. J., Alsheikh-Ali, A. A., Rajab, M., Estes, M. A., and Link, M. S. 2009. Precordial thump for cardiac arrest is effective for asystole but not for ventricular fibrillation. Heart Rhythm 6:1495-1500.



> The efficacy of precordial thump for termination of induced non-tolerated ventricular tachyarrhythmias  is very low even with application early after the onset of arrhythmia. Our study provides new evidence about this safe but generally non-productive manoeuvre, which may inform future revisions of cardiopulmonary resuscitation guidelines.



Haman, L., Parizek, P., and Vojacek, J. 2009. Precordial thump efficacy in termination of induced ventricular arrhythmias. Resuscitation 80:14-16.


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## usafmedic45 (May 29, 2010)

> Interesting, I kind of assumed that head injury would be more prevalent



It is actually.  It's just that the scope of that study is too narrow to show it.  There's a very broad continuum of "head injury" (high frequency, low mortality) where as commotio cordis has a very high mortality despite a much lower frequency.  



> It's V Fib, not asystole. Initially anyways.



You can get asystole from blunt chest impact, although not commonly, but that is beside the point.  You're missing what I am trying to get across.  You can not accurately compare a group that on presentation to medical professionals are in a multitude of rhythms (especially mostly non-VF/VT) with a group that on presentation to medical professionals are in soley VF/VT and expect to get results that have validity.  I don't know how much more clear I can make it without being unnecessarily (from a professional perspective since I think you're normally pretty sharp and personal standpoint since I consider you a friend) degrading.   In other words, the two studies (or rather the Madias study and the VF/VT subset of the study you cited) are not looking at the same thing, even though they are both looking at "cardiac arrest outcomes".  Does that make any sense? 



> Madias, C., Maron, B. J., Alsheikh-Ali, A. A., Rajab, M., Estes, M. A., and Link, M. S. 2009. Precordial thump for cardiac arrest is effective for asystole but not for ventricular fibrillation. Heart Rhythm 6:1495-1500.



That's the one I was referring to....just never got around to looking for it.  Thank you!


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## LucidResq (May 29, 2010)

Case study of precordial thump causing commotio cordis...

Precordial thump was performed due to complete AV block. 



> A precordial thump was performed to restart cardiac activation. Unfortunately, the precordial thump occurred during repolarization of the first ventricular escape rhythm, resulting in ventricular fibrillation, which required external cardioversion.



Cayla, G., Macia, J. C., and Pasquie, J. L. 2007. Precordial thump in the catheterization laboratory experimental evidence for commotio cordis. Circulation 115:e332+.


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## LucidResq (May 29, 2010)

Oh USAF I wasn't arguing with you, I was referring to this: 


Lifeguards For Life said:


> The treatment of Commotio Cordis  is no different from any other cardiopulmonary emergency associated with asystole.



I understand your point about cherry-picking data and such and know that one cannot truly compare the two studies, I just wanted to show that I wasn't completely coming out of left field when I said resus. is futile. In retrospect, probably not the best choice of words, but the survival rate is still low - just as it is with any out-of-hospital cardiac arrest. Of course early defib and CPR would save many of these kid's lives, but in the current situation this often isn't the case.


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## Lifeguards For Life (May 29, 2010)

LucidResq said:


> Case study of precordial thump causing commotio cordis...
> 
> Precordial thump was performed due to complete AV block.
> 
> ...



Third-degree  AVB is not v-fib or asystole. I'll have to look for the studies, but I believe the risks of a precordial thump are relatively low in a non pulse producing rhythm.

I generally hate anecdotal evidence, but I have seen one patient convert from V-fib following a precordial thump. 

I'll try to locate a few studies on the use of precordial thump in witnessed v-fib/ non pulse producing rhythms.


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## usafmedic45 (May 29, 2010)

> Oh USAF I wasn't arguing with you



Ah...that explains it.  I couldn't figure out why you were not picking up what I was saying.  



> I just wanted to show that I wasn't completely coming out of left field when I said resus. is futile.


I don't think a 1 in 5 survival rate is all that bad, especially when with improved interventions we could easily raise it.  Your definition of futile is a pretty loose.



> In retrospect, probably not the best choice of words, but the survival rate is still low - just as it is with any out-of-hospital cardiac arrest.



Understood...see my comments below.



> Of course early defib and CPR would save many of these kid's lives, but in the current situation this often isn't the case.



Which is why we must choose our words carefully and fully understand what they mean.  Poor choices of words can discourage someone (perhaps one of the members on this list) from taking actions that might have significant impact on the outcomes of cases like this.


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## LucidResq (May 29, 2010)

Lifeguards For Life said:


> Third-degree  AVB is not v-fib or asystole. I'll have to look for the studies, but I believe the risks of a precordial thump are relatively low in a non pulse producing rhythm.


 I know it isn't and I wasn't trying to use that study as evidence that precordial thumps are ineffective or harmful.... just thought it was interesting, since it's been mentioned on here that precordial thumps have caused commotio cordis, this was just an example. 

I agree, the risks are generally low. I did dig this up though... 



> Our case highlights a previously undocumented complication following the use of a precordial thump: sternal fracture and osteomyelitis. This necessitated a modification to his coronary artery bypass graft surgery, and he required 6 weeks of intravenous antibiotics.



Ahmar, W., Morley, P., Marasco, S., Chan, W., and Aggarwal, A. 2007. Sternal fracture and osteomyelitis: An unusual complication of a precordial thump. Resuscitation 75:540-542.

Again, just a single case, but interesting (kinda crazy actually). 

Other reported complications include deterioration of VT into VF, rate increase in VT, rib fractures, myocardial contusion, etc.... I guess it comes down to a risk-to-benefit thing which is complicated with these patients. Of course, chest compressions have the potential to cause similar types of physical damage... not sure about the effects on VT. 

Sclarovsky, S., Kracoff, O. H., and Agmon, J. 1981. Acceleration of ventricular tachycardia induced by a chest thump. Chest 80:596-599.

Sclarovsky, S., Kracoff, O., Arditi, A., Strasberg, B., Zafrir, N., Lewin, R. F., and Agmon, J. 1982. Ventricular tachycardia "pleomorphism" induced by chest thump. Chest 81:97-98.

Befeler B. Mechanical stimulation of the heart. In Befeler B, editor. Selected topics in cardiac arrhythmias. New York: Futura Publishing Co, 1980; 185.


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## Lifeguards For Life (May 29, 2010)

LucidResq said:


> I know it isn't and I wasn't trying to use that study as evidence that precordial thumps are ineffective or harmful.... just thought it was interesting, since it's been mentioned on here that precordial thumps have caused commotio cordis, this was just an example.
> 
> I agree, the risks are generally low. I did dig this up though...
> 
> ...




The AHA makes no recommendation for or against the use of the precordial thump by ACLS providers. However, the 2005 the International Liason Committee  On Resuscitation guidelines indicate that one precoridal thump may be considered after a _monitored_ cardiac arrest if a defibrillator is not immediately available.

The precordial thump should be considered within the first fifteen seconds of v-fib or pulse less v-tach (monitored arrests) if defibrillation is not immediately accessible [CLASS B; LOE IV]

In the case of witnessed arrest, out of hospital, after a baseball to the chest, after activating the emergency response system, I would still probably opt for the precordial thump.


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## Melclin (May 29, 2010)

*Cricket > Baseball*

Cop a rick arm quick off a patchy wicket and you'll know all about it. Base ball is for sheilas 




VirginiaEMT said:


> 1.What is hyperglycemia? It is my thought that it simply means an excessive blood gluose level. The patient had a D-stick of 175, he said normal is around 120. He was laying on a bench at Wal-Mart, with an altered LOC, but signed a patient refusal because he was feeling better and didn't want to go with us.



Blood sugar can spike a little after corrections after a hypo. And it can then shoot back down. It's a little unclear what happened exactly, but I would be a little unhappy leaving him considering her was altered and you didn't have a BSL to definitely connect with his LOC, until he was very GCS 15, as long as he is a known diabetic and knows the score about post hypo big sandwich eating.  



VirginiaEMT said:


> I thought anything above a 140, for anyone is considered hyperglycemic?



The lower limit is far more definite than the upper limit. 



VirginiaEMT said:


> The AIC started asking her questions about WHY she did it, and started telling her that suicide was no way out


[/QUOTE]

Suggesting solutions or preaching at a person about suicide not being the answer is a poor choice in regards to someone who has just tried to kill themselves. It won't help and it may alienate them. It reflects the clinicians opinions on, and difficulty dealing with, the concept of suicide more than anything. I think as prehospital providers the most important thing is to do aside from showing the pt compassion (putting aside the fact that you yourself may be angry about the selfishness of suicide etc), is to collect information about the person's triggers, lifestyle, environment and support structure. It may be directly relevant to the pt's MSE and decision to discharge later down the track. 

http://emedicine.medscape.com/article/288598-overview -- have a look at the risk factors section, and the suicide-typical MSE. 





> empathizing with the patient's pain helps them feel more trusting and understood, the physician can subtly begin inculcating hope with a positive attitude, a belief that the patient's circumstances and depression can improve and be treated successfully.



- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419387/ -- I believe we do the first part of what that sentence mentions. We empathize. Correcting faulty logic is not appropriate at the point of crisis and it is something that a psychiatrist should be doing slowly over the next few days or weeks.


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## Focallength (May 29, 2010)

Not to berate the OP, but how on earth can you be a EMT-B and not know what hyperglycemia is? Sorry but that is scary, are you in a non-NREMT state and they didnt go over this?

do you know what insulin shock/ diabetic coma is? 

please dont take this the wrong way, I really am curious as to why you dont know what hyperglycemia is. It could be that Iam misreading your question too.

Also have you ever had a NC at 6lm in your nose? it feels like a blow dryer. Most patients would rip that thing out or complain that their nares are dry and bleeding in a few seconds. In my experience 9limited as it may be) different places have different protocols, NR may say place another bandage on top of the first, but your MD may rule otherwise.


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## WashboardSlim (May 29, 2010)

So essentially what we have here is High Mortality and Low Frequency vs Low Mortality and High Frequency, right? Personally and purely from a statistical viewpoint, give me a serious thud to the chest - or, better yet, how about a better pitcher? 

Also, there seems to be a torrent of fact-checking, case studies and references being thrown around in regard to commotio cordis and the precordial thump, and that's all well and good, but let's set up a scenario:

You've just been nailed in the sternum with a 149 gram baseball traveling at 90 mph - it has a kinetic energy of roughly 121 joules.  

One of your team mates rushes to your side - turns out he's a bona fide medic student! He checks your ABC's and it looks like you're SOL - no pulse. It's going to be a little while before they grab the AED - say, 5 minutes. Now, your buddy knows how to do a precordial thump... And he looks awfully strong, so maybe he could whack you with 10 joules in the meantime. Would you want him to?

Now, before you answer, consider the Quantum Immortality thought experiment. Essentially, we'll be looking through the eyes of Schrodinger's cat for this one. For all intents and purposes, let's say with all the variables in play - the fact that we don't really know what rhythm you're in, nor the exact  amount of energy needed to convert you, nor the amount one can provide at this exact moment - so let's call it 50-50. 

Let's say he does it - if the many-worlds interpretation is correct, at this exact moment the universe will split to accommodate all possible outcomes, meaning you'll live and die several times over (which won't matter a whole lot, because as a conscious entity you'll cease to exist entirely, so we'll disregard these). Now, in the worlds that you HAVE survived, reality will continue to be observed and the chance of fatality will appear to have decreased. And for every precordial thump after the incident, it will appear to be less of a 50-50 shot (however, you will never reach a 0% chance of mortality). 

So, essentially, the only way to decrease the chance of mortality is to let it ride and administer the precordial thump.


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## VirginiaEMT (May 30, 2010)

Focallength said:


> Not to berate the OP, but how on earth can you be a EMT-B and not know what hyperglycemia is? Sorry but that is scary, are you in a non-NREMT state and they didnt go over this?
> 
> *Of course I know what it is.. If you would read the original post, I was clarifying what I was told by an EMT-E. I wanted to make sure my understanding was correct.*
> 
> ...


*
I guess he has....*

He may have.


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## VirginiaEMT (May 30, 2010)

This is a continuance from my last post. I am a vounteer that runs 1-2 nights a week, and I don't get to ask people questions every day of the week. I have been told by several  EMT-E's and EMT-I's that I am one of the most competent BLS providers that they run with. I want to get really good at what I do, and advance in levels as time goes on. 

So far, other than your post, this forum has been very generous with helping me and answering questions.

Please don't take this the wrong way, but I am usually seeking answers from people with a lot more knowledge than me, which means a Paramedic, EMT-E, EMT-I, etc. These are the people who can help me grow, and give me answers to the questions I may have because I want to know as much about the particular topic of my questions, and an EMT-B may not be able to provide that for me.

Keep on keepin on.


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## usafmedic45 (May 30, 2010)

> Not to berate the OP, but how on earth can you be a EMT-B and not know what hyperglycemia is? Sorry but that is scary, are you in a non-NREMT state and they didnt go over this?



Even as the reigning "kick the newbie in the nuts" champ on EMTLife, I have to say that's a bit excessive.  I've never seen it listed in a basic textbook where the problems begin with hyperglycemia.  The symptoms?  Yeah, but not the levels since in most states they (unless they were with a medic partner) never know the level in the field.  I don't agree with it, but hey, I don't write the standards.



> It could be that Iam misreading your question too.


You are. What he asked was: 


> I thought anything above a 140, for anyone is considered hyperglycemic?



Which is "technically" correct: 140 is the high end of normal fasting glucose range...granted it's not going to cause major problems but it's smart of the OP to ask about it.  BTW, to the OP, yes, that's normal for someone's glucose to spike (slightly) after eating.  It's why they tell you to fast before you are tested for diabetes. 



> complain that their nares are dry and bleeding in a few seconds.



14 years in EMS, 9 as an RT and I've never seen a nosebleed _that fast _from a nasal cannula.  Not saying it is never going to happen, but I would not say that "most patients" experience it.  The dry part, yes....any O2 through a cannula above two liters really should be humidified if at all possible.



> In my experience 9limited as it may be) different places have different protocols, NR may say place another bandage on top of the first, but your MD may rule otherwise.



That is pretty much the standard practice.  Never remove a dressing while bleeding is still ongoing.  Personally I never remove it until at least 30 minutes after I've gotten the bleeding stopped or until I get to the hospital, whichever happens first.  When working in EMS, it was always the latter.


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## ajax (May 31, 2010)

I just want to add to the BSL discussion that if someone is feeling hypo at 200, they need resources to help them manage their diabetes better. Yes, some people are normally at 3-400s, but that isn't healthy, and getting a 3-400 BG patient to the ER is generally a good call. 

I'd be more concerned about a pt with a 300 and ALOC than a pt with 50 and ALOC - the 50 can be easily treated at home (as long as the pt is conscious and hasn't had something unusual happen - like a pump malfunctioning and injecting 3 days of insulin in a matter of seconds) and the 300 is likely to progress to DKA. If the pt has an altered LOC with hyperglycemia (real high - 175 doesn't fit this bill), they're nearing DKA. DKA can cause cerebral edema, shock (from severe dehydration), and lots of other gross things, eventually leading to death - and the depletion of potassium in treating DKA (without an IV drip) can threaten cardiac rhythm.

I think that when we learn that lows are more dangerous than highs (immediately), we forget how dangerous highs can be (longer term, although especially for type 1 folks, not that much longer - DKA can happen in a matter of hours). However, a known diabetic without an ALOC and a BG of 300 wouldn't really concern me, except i'd wonder what inspired them to call... 

Also, after hypoglycemia, BG spiking is normal, and LOC trails that - so people will sometimes still "feel" 50 twenty minutes after the 50, when their BG is now 175. The note about dropping again is important, too. Rapid spikes lead to rapid drops, so watch your patient eat something with protein, fat, and carbs before you let them sign out AMA.


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## MrBrown (May 31, 2010)

VirginiaEMT said:


> This is my point, wouldn't this be a reason for the high flowo2. It would have been my guess that because of the blood loss, we should have given high flow o2 to prevent her from becoming shocky instead of waiting for her to get shocky.



Hmmm ..... more on this later.

I need sleep before I die, good day now.

*Brown takes off his orange jumpsuit and gets into bed.


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## usafmedic45 (May 31, 2010)

> we should have given high flow o2 to prevent her from becoming shocky instead of waiting for her to get shocky



Seriously....I don't have polite words to describe how....never mind....I'm not getting banned over this. 

Go review what causes hypovolemic shock instead of buying more equipment.  It's better to stock your brain with information than your car with gear you may not know when (or more importantly, when not to use it) and how to use.


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## MrBrown (May 31, 2010)

usafmedic45 said:


> I'm not getting banned over this.



Seriously!


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## VirginiaEMT (May 31, 2010)

usafmedic45 said:


> Seriously....I don't have polite words to describe how....never mind....I'm not getting banned over this.
> 
> Go review what causes hypovolemic shock instead of buying more equipment.  It's better to stock your brain with information than your car with gear you may not know when (or more importantly, when not to use it) and how to use.



*Yeah whatever. I guess I need to get te 80's out of my mind, where I ran as an EMT for 7 years, and get into 21st century thinking.  You may have been in diapers back then, but we would absolutely woul not give a COPD patient more than 2lpm O2 via NC, regardless, not exceptions. We had hyperventilating patients breathing into paper bags. I need to get that old crap out of my head and start doing things the way they are done today.

By the way, if you have something to add, feel free, I'm a really big boy.
If I value your opinion, I may be offended, if not, well you get the point.*


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## VirginiaEMT (May 31, 2010)

opps, double post


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## VirginiaEMT (May 31, 2010)

usafmedic45 said:


> Seriously....I don't have polite words to describe how....never mind....I'm not getting banned over this.
> 
> Go review what causes hypovolemic shock instead of buying more equipment.  It's better to stock your brain with information than your car with gear you may not know when (or more importantly, when not to use it) and how to use.



*EXPLANATION*


My textbook BRADY Emergency care 11th Edition

Chapter: Bleeding and Shock page 621

Of course direct pressure,elevation,pressure point, and last resort torniquet

BUT it also states word for word under PATIENT CARE

_In addition to controlling bleeding, an important treatment  for ANY TRAUMA PATIENT is "administration of oxygen"
Blood loss decreases perfusion. This means that LESS oxygen is delivered to the tissues. The administration of supplemental oxygen will increase the oxygen saturation of the blood that is still in the patients circulatory system, improving oxygenation of the tissues._

Everything I studied about oxygen stated 15 LPM via NRB is the answer. The state Exam, the practicals, the class exam, the class final exam........... 

It would be a great help if you would simply say " You may have misunderstood blah,blah,blah, but this is a correct way of doing blah,blah,blah, or maybe you could suggest reading material, or online training, etc. 

I would really appreciate your help..


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## JPINFV (May 31, 2010)

Oxygen administration will not stop shock due to blood loss. Similarly, it will not decrease hypoxia in a patient with a saturation near 100% since the differenece in dissolved concentration goes from extremely tiny to very very tiny.

CaO2 = (SaO2 x Hb x 1.34) + .003(PaO2)


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## Ridryder911 (May 31, 2010)

VirginiaEMT said:


> *Yeah whatever. I guess I need to get te 80's out of my mind, where I ran as an EMT for 7 years, and get into 21st century thinking.  You may have been in diapers back then, but we would absolutely woul not give a COPD patient more than 2lpm O2 via NC, regardless, not exceptions. We had hyperventilating patients breathing into paper bags. I need to get that old crap out of my head and start doing things the way they are done today.
> 
> By the way, if you have something to add, feel free, I'm a really big boy.
> If I value your opinion, I may be offended, if not, well you get the point.*



I was an Paramedic in 70's and 80's and sorry I even knew better than that back then.. I was taught "oxygen toxicity" was a myth. One of the ONLY reasons was not that you would shut down respiratory drive BUT you could not handle and control airway and respiratory depression. Hence... was told to withhold than to really know what to do. The same crap nurses was taught until they figured out critical and emergency nurses can be taught be and be educated in airway management. 

Please; also quoting from an EMS textbook is embarrassing as most are only written at elementary or mid-level. So scientific and true medical information needs to have other resources and references. 

R/r 911


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## EMTinNEPA (May 31, 2010)

Oxygen will not fix hypovolemic shock.  The problem is not a lack of oxygen, it is a lack of circulating blood with hemoglobin to deliver oxygen to the cells of the body due to hemorrhaging.

Yes, oxygen can kill the hypoxic drive of a COPDer, but not during the 20 minute ride to the hospital.  You NEVER withhold oxygen from somebody who needs it.

As for the emotional coaching of the suicidal patient, we're here to treat patients... sometimes their problems are more psychological than anything.  Also, her pupils may be dilated, but I'm willing to bet that's mostly sympathetic tone.  If her color is good and she's hemodynamically stable, then why treat for shock?  I understand if she's tachycardic that may be a little concerning, but if the blood loss wasn't that significant, I wouldn't worry... again probably more sympathetic tone than anything else.

As for commotio cordis, it's been pretty well covered.  The only thing I can add is that it can only occur during a very short window in ventricular repolarization called the "relative refractory period".


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## VirginiaEMT (May 31, 2010)

Ridryder911 said:


> I was an Paramedic in 70's and 80's and sorry I even knew better than that back then.. I was taught "oxygen toxicity" was a myth. One of the ONLY reasons was not that you would shut down respiratory drive BUT you could not handle and control airway and respiratory depression. Hence... was told to withhold than to really know what to do. The same crap nurses was taught until they figured out critical and emergency nurses can be taught be and be educated in airway management.
> 
> Please; also quoting from an EMS textbook is embarrassing as most are only written at elementary or mid-level. So scientific and true medical information needs to have other resources and references.
> 
> R/r 911



Big difference in a Paramedic and an EMT-A, heck we did not even have Paramedics in this area, heck we didn't even man the station, in the 80's.We still don't have very many Paramedics. I believe the highest level in this area in the 80's was a shock trauma tech. It's been a while. I think the only paramedic I saw was on Emergency.

I quoted out of the book to explain my confusion not to prove I was right. I only used it to show what I was taught and where the confusion is coming from.


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## VirginiaEMT (May 31, 2010)

EMTinNEPA said:


> Oxygen will not fix hypovolemic shock.  The problem is not a lack of oxygen, it is a lack of circulating blood with hemoglobin to deliver oxygen to the cells of the body due to hemorrhaging.
> 
> Yes, oxygen can kill the hypoxic drive of a COPDer, but not during the 20 minute ride to the hospital.  You NEVER withhold oxygen from somebody who needs it.
> 
> ...




Thank you for your help.


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## got_shoes (May 31, 2010)

EMTinNEPA said:


> Yes, oxygen can kill the hypoxic drive of a COPDer, but not during the 20 minute ride to the hospital.  You NEVER withhold oxygen from somebody who needs it.



Okay, I have a slightly different perspective on this, *there is one true contra-indication for O2 admin, that would be paraquat poisoning.*


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## EMTinNEPA (May 31, 2010)

VirginiaEMT said:


> Thank you for your help.



No problem.


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## reaper (May 31, 2010)

got_shoes said:


> Okay, I have a slightly different perspective on this, *there is one true contra-indication for O2 admin, that would be paraquat poisoning.*



There is no true contraindication for Oxygen, in the emergency setting. Yes, Paraquat poisoning should be handled with care. But, if they need O2, they need O2. Hypoxia will kill faster the then the Paraquat!


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## got_shoes (May 31, 2010)

Paraquat poisoning will be further along with high concentrations of O2, there is no doubt about this, I can find plenty of sources all over the internet. In emergency care if someone needs help with their breathing, bag them on room air, that is assisting their ventilations to some point. I will concede that it is not ideal, but I would suggest that is a true contraindication. If you give 100% O2 at 15 lpm, then I would say that would be EMS assisted suicide.


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## adamjh3 (May 31, 2010)

Shoes, I would like to see a couple sources if you wouldn't mind, I've done a quick search and turned up nothing to support either side.


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## Lifeguards For Life (May 31, 2010)

got_shoes said:


> Paraquat poisoning will be further along with high concentrations of O2, there is no doubt about this, I can find plenty of sources all over the internet. In emergency care if someone needs help with their breathing, bag them on room air, that is assisting their ventilations to some point. I will concede that it is not ideal, but I would suggest that is a true contraindication. If you give 100% O2 at 15 lpm, then I would say that would be EMS assisted suicide.




No specific contraindications to oxygen therapy exist when indications are judged to be present.

Paraquat has an affinity for the lung, in which it is selectively absorbed and accumulates within type I and type II alveolar epithelial cells. Within these cells, paraquat generates oxygen free radicals that ultimately damage lipid membranes and cause cell death. The initial acute lung injury may progress to acute respiratory distress syndrome. Those patients who do survive enter a proliferative phase characterized by loss of alveolar integrity, proliferation of fibroblasts, and deposition of collagen, leading to pulmonary fibrosis. 

 Ironically, oxygen supplementation may have a deleterious effect because it increases the number of toxic radicals. Oxygen should therefore be given only to prevent hypoxemia. Anoxic injury will be much more harmfull to the patient than damage to pulmonary parenchyma.

The poison control center does not advise withholding oxygen, to patients with suspected paraquat poisoning.



> If you give 100% O2 at 15 lpm, then I would say that would be EMS assisted suicide.



Take everything you are told in school with a grain of salt. Oxygen, even 15lpm is not a death sentence in any form of dipyridyl compounds poisonings.

"In which form of organophosphate poisoning is oxygen immediately lethal?", has long been a 'fad' EMS question, with many providers claiming paraquat, with little to no understanding of why.


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## got_shoes (Jun 1, 2010)

so a few things first and fore most; The hypoxemia definition as decreased partial pressure of oxygen excludes decreased oxygen content caused by anemia (decreased content of oxygen binding protein hemoglobin) or other primary hemoglobin deficiency, because they don't decrease the partial pressure of oxygen in blood.
Still, some simply define it as insufficient oxygenation or total oxygen content of (arterial) blood, which, without further specification, would include both concentration of dissolved oxygen and oxygen bound to hemoglobin. Inclusion of the latter would include anemia as a possible cause of hypoxemia (which, however, is not the case generally). And such hypoxia is referred to as hypoxemic hypoxia, which is distinguished from e.g. anemic hypoxia. Because of the frequent incorrect use of hypoxemia, this is sometimes erroneously stated as hypoxic hypoxia. source: wikipedia and just in case there is an issue with wiki here is another one, The main symptom of hypoxemia is shortness of breath, but depending on how quickly hypoxemia develops, you may experience a reduced capacity for exercise, fatigue and confusion. source:mayoclinic.com

the biggest point that I am trying to make here is that oxygen is not indicated in cases of paraquat poisoning. it is not going to help, *life* even in the same article that you posted, which you copied and pasted into a response to this, says not to with hold but no where in the article does it say you can't use room air or if their is a certain amount of oxygen delivered to these pt's. Along the same lines though the Hypoxemia is different from hypoxia, which is an abnormally low oxygen availability to the body or an individual tissue or organ. Still, hypoxia can be caused by hypoxemia. Source wikipedia.

I don't believe everything that I hear in class until i have time to research a subject on my own. although I will say this much paraquat is unlikely to be seen to much here in America seeing as for the most part it has been outlawed and the few places that do use need to have a licensed person apply this product. 

Life I will also say that for the most part oxygen should never be with held from a pt that does actually need it. but at the same time a lot of EMS providers think oxygen should always be applied no matter what. the purpose of this to me was to high light maybe just maybe that oxygen doesn't need to be delivered. But since I have said that paraquat is for the most part been outlawed in the US then in a way we are both right.


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## mcdonl (Jun 2, 2010)

*Much better now...*

Well now, that certainly clears up any confusion a new basic may have. Thanks guys!


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## ajax (Jun 2, 2010)

Something new to throw into the mix:

A study at Cooper Union Hospital showed increased post cardiac arrest survival rates with lower levels of O2 - better with sp02 <90 than with sp02 at 100, best with sp02 94-96. 

http://www.emsresponder.com/article/article.jsp?id=13503&siteSection=1


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## reaper (Jun 2, 2010)

Has already been mentioned in a seperate thread. 

Take little from a study conducted at one hospital. Some thing like that would need a broad study done.


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## ajax (Jun 2, 2010)

> Cooper researchers conducted the study with experts from the Carolinas Medical Center in Charlotte, N.C., Beth Israel Deaconess Medical Center in Boston, and Ohio State University in Columbus.



Who knows what exactly that means in terms of data, sample size, etc. I'll wait for the peer reviewed journal article. But this is not the first piece of evidence that excess O2 can cause harm. Keyword: excess.


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## VirginiaEMT (Jun 2, 2010)

WOW, this is the BLS discussion board isn't it.


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## JPINFV (Jun 2, 2010)

EMT-Bs administer oxygen, correct?


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## Veneficus (Jun 2, 2010)

*O2. What exactly is it doing?*



got_shoes said:


> Life I will also say that for the most part oxygen should never be with held from a pt that does actually need it. but at the same time a lot of EMS providers think oxygen should always be applied no matter what..



Not directed at anyone, but food for thought.

"When it is needed" is exactly the point.

Lets look at blood loss from trauma. There is a great push to find something that will transport and gie up oxygen in the body.

If you add 15L of NRB but losing the blood that carries the oxygen, all you are doing is adding free radicals. Can we agree that adding oxygen when there is no ability to transport it to tissues doesn't really do anything productive?

consider any shock for that matter.

Look at the plethora of airway diseases where o2 intake is not the issue. If there is already enough O2, how does adding more help?

Forget hypoxic drive, and all the myth surrounding that, if you have one functioning alveoli out of 10 or more, does adding oxygen increase the surface area for gas exchange? How?

Want to see? get a straw and some bubbles. Put one bubble on one end of the straw and a second bubble opposite. They don't equal in pressure, one gets smaller and one gets bigger.

What about oxygen as a vasoconstrictor? Does constricting coronary arteries in an ACS seem like it would be of benefit?

EMS relly boarders on snake oil sales. Mythological magical traditions and catch phrases that withstand evidence to the contrary. Is that the mark of medical professionalism?

"If some is good more is better???"

I am not suggesting oxygen, even at 10L NRB never helps, only that there are relatively few times it does. 

It is nice to turn phrases like "don't withold when needed." But with such little need, perhaps withholding is a better standard than flooding in all cases?


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## EMTinNEPA (Jun 2, 2010)

JPINFV said:


> EMT-Bs administer oxygen, correct?



^_^

You really don't know how much that make me giggle.


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## jjesusfreak01 (Jun 2, 2010)

EMTinNEPA said:


> ^_^
> 
> You really don't know how much that make me giggle.



Are you sure we don't need to call in to use O2?


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## EMTinNEPA (Jun 3, 2010)

jjesusfreak01 said:


> Are you sure we don't need to call in to use O2?



Only in California


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## VirginiaEMT (Jun 3, 2010)

JPINFV said:


> EMT-Bs administer oxygen, correct?




si senior


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## got_shoes (Jun 3, 2010)

VirginiaEMT said:


> WOW, this is the BLS discussion board isn't it.



I realize that this has been :deadhorse: but, I think that the more EMT's see/read/hear about, maybe just maybe it might cause them to look things up and do some of their own research on different subject. Just because it isn't taught in an EMT basic program doesn't mean they don't need to know about it.


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## jjesusfreak01 (Jun 3, 2010)

*Verified hyperventilation...*

We can withhold Oxygen in the case of verified hyperventilation, right? 

So long as we verify with spO2 and there are no indications of other pulmonary or cardiac problems, we can withhold it?


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## Shishkabob (Jun 3, 2010)

How are you as an EMT going to rule out other causes cardiac in origin, or elsewhere?  Negative signs does not mean negative presence.


Heck, we still can't rule everything out as a medic. 




Now, that doesn't mean I won't treat it as such, if it's my DDX.


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## got_shoes (Jun 3, 2010)

*it depends on your protocols*

Why would you want to with hold o2 in that situation? SpO2 reading may be a little off in that case, along with person's suffering from hyperventilation may have spasm's in the extremities, in extreme cases. the hyperventilation may be a  issue of other cardio-respiratory disease. further more if you can convince your Pt. that the o2 will help with their hyperventilation, their respiratory rate may decrease.


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## jjesusfreak01 (Jun 3, 2010)

got_shoes said:


> Why would you want to with hold o2 in that situation? SpO2 reading may be a little off in that case, along with person's suffering from hyperventilation may have spasm's in the extremities, in extreme cases. the hyperventilation may be a  issue of other cardio-respiratory disease. further more if you can convince your Pt. that the o2 will help with their hyperventilation, their respiratory rate may decrease.



Right, it is certainly true that talking down the patient while on oxygen will both fix the hyperventilation and won't put the patient at additional risk from lack of oxygen, but if the history (especially events leading to problem) as well as spO2 should give you a good idea if it is hyperventilation. Obviously, in this case you would want to start the oxygen immediately if there was any question, but are there any conditions other than hemoglobin binders (CO) that will give an spO2 reading of 100% and present with the same breathing symptoms? Seeing as most cardiac and pulmonary problems reduce blood oxygen content and most people are around 98% or less on room air, 100% would seem to be a good indication of hyperventilation.

This is really just a thought experiment of course, because once I get oxygen on the patient I will expect to see near or at 100% on the pulseox anyways, so it will be useless as a diagnostic tool for hyperventilation, except that spO2 of less than 100% on a NRB will pretty much indicate that it is not hyperventilation.


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## MonkeySquasher (Jun 4, 2010)

jjesusfreak01 said:


> but are there any conditions other than hemoglobin binders (CO) that will give an spO2 reading of 100% and present with the same breathing symptoms?




Yes and no.  CO will bind with the hemoglobin and result in a falsely high SPO2 reading, but the patient will present as general illness, bright red cheeks, and possibly altered mental.  There may or may not be breathing problems.




jjesusfreak01 said:


> Seeing as most cardiac and pulmonary problems reduce blood oxygen content and most people are around 98% or less on room air, 100% would seem to be a good indication of hyperventilation.
> 
> This is really just a thought experiment of course, because once I get oxygen on the patient I will expect to see near or at 100% on the pulseox anyways, so it will be useless as a diagnostic tool for hyperventilation, except that spO2 of less than 100% on a NRB will pretty much indicate that it is not hyperventilation.



Negative.  People can have a "normal" SPO2 of anywhere from high 80s (chronic COPD) to 100%.  I normally have a 99-100% reading, but only normally breathe 8-10/min.

Conversely, it's quite possible to have a person hyperventilating at 30/min with an SPO2 of 95%, or higher/lower.  Hyperventilation is a representation of respiratory rate.  SPO2 is a representation of gas exchange in the lungs/blood.  Respiratory rate is no indicator of gas exchange.


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## Shishkabob (Jun 4, 2010)

Really there is no point in withholding O2 from someone that is hyperventilating from an anxiety disorder.  Give 'em O2, and one of 2 things will happen:

They'll calm down, or they'll pass out.  Either way they'll be breathing back to normal in no time.



THat IS, if it's just anxiety and not some other underlying cause such as cardiac in origin.


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## MonkeySquasher (Jun 4, 2010)

Linuss said:


> They'll calm down, or they'll pass out.  Either way they'll be breathing back to normal in no time.




haha.  Eventually, the body hits the Reset button and all is well.  B)


...Or you suddenly get a lot more busy.


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## jjesusfreak01 (Jun 4, 2010)

MonkeySquasher said:


> Negative.  People can have a "normal" SPO2 of anywhere from high 80s (*chronic* COPD) to 100%.  I normally have a 99-100% reading, but only normally breathe 8-10/min.



As opposed to the other type of COPD...

Thanks for all the information. I think these types of discussions help me get a much better grasp on concepts and are really helpful. I'll bet the originator of this thread would agree.


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## Aidey (Jun 4, 2010)

Linuss said:


> That IS, if it's just anxiety and not some other underlying cause such as cardiac in origin.



The issue I have with putting O2 on anxiety patients is that it can reinforce the patient's mindset that it is a problem that can just be "fixed" with medication, or the idea that it is some other problem and not anxiety. 

Obviously patients with anxiety can have other things going on, but I think it is important for patients who have anxiety to understand their anxiety and what it feels like so they know what is going on. Kind of like asthma patients and asthma, or seizure patients and auras. Not that you should let patients suffer or anything like that, its just that for the patient understanding they are having an anxiety attack can help prevent the process from progressing. Continually short circuiting that process can negatively affect the patient. 

There could also be hematologic causes, namely most of the anemias.


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## mcdonl (Jun 4, 2010)

*According to my training and state protocols....*

If a patient is having difficulty or SOB I am to give O2... I am a basic, I do not diagnose. I was taught never under any circumstance should I withold O2.


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## got_shoes (Jun 4, 2010)

A provider's job is to know the human body and its functions in terms of normality (homeostasis). The four cornerstones of diagnostic medicine, each essential for understanding homeostasis, are: anatomy (the structure of the human body), physiology (how the body works), pathology (what can go wrong with the anatomy and physiology) and psychology (thought and behavior). Once the provider knows what is normal and can measure the patient's current condition against those norms, she or he can then determine the patient's particular departure from homeostasis and the degree of departure. This is called the diagnosis. Once a diagnosis has been reached, the provider is able to propose a management plan, which will include treatment as well as plans for follow-up. From this point on, in addition to treating the patient's condition, the provider educates the patient about the causes, progression, outcomes, and possible treatments of his ailments, as well as providing advice for maintaining health. source: wikipedia

Based upon those criteria, how would you know when medical Pt's need intervention at a hospital, and which hospital would be best for you Pt.?


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## Shishkabob (Jun 4, 2010)

Aidey said:


> The issue I have with putting O2 on anxiety patients is that it can reinforce the patient's mindset that it is a problem that can just be "fixed" with medication, or the idea that it is some other problem and not anxiety.
> 
> Obviously patients with anxiety can have other things going on, but I think it is important for patients who have anxiety to understand their anxiety and what it feels like so they know what is going on.




True, true.  I don't advocate doing a NRB for these types of patients but I still support SOME oxygen. as it does make them think you're doing something and that in and of itself calms them down..  At most it would be a simple face mask.

I had a patient back in February, 14yo having 'chest pain' after being arrested by PD, so we were called out.  Did my full assessment, no cardiac history, history of drugs, CP "11/10" started right when he was arrested, hyperventilatory ratre of 30's carpalpedal spasms, High SpO2, low EtCO2.


I gave him a NC at 4lpm and coached him down making him look at the EtCO2 readings, trying to get them back above 35.  We still ended up transporting because the cop didn't feel safe with it.


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## Trayos (Jun 4, 2010)

> True, true. I don't advocate doing a NRB for these types of patients but I still support SOME oxygen. as it does make them think you're doing something and that in and of itself calms them down.. At most it would be a simple face mask.


Like the placebo effect?


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## irish_handgrenade (Jun 9, 2010)

MonkeySquasher said:


> SPO2 is a representation of gas exchange in the lungs/blood.  Respiratory rate is no indicator of gas exchange.



Actually SPO2 is a representation or the percentage of available hemoglobin is bonded with O2 or CO. Endtidal capnography is a representation of gas exchange within the lungs/blood...


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## jjesusfreak01 (Jun 9, 2010)

irish_handgrenade said:


> Actually SPO2 is a representation or the percentage of available hemoglobin is bonded with O2 or CO. Endtidal capnography is a representation of gas exchange within the lungs/blood...



What effect will CO poisoning have on SPO2 readings?


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## TransportJockey (Jun 9, 2010)

jjesusfreak01 said:


> What effect will CO poisoning have on SPO2 readings?



It can  make SPO2 read at 100%. CO has a much higher affinity to hemoglobin than O2


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## jjesusfreak01 (Jun 9, 2010)

jtpaintball70 said:


> It can  make SPO2 read at 100%. CO has a much higher affinity to hemoglobin than O2



Sorry, I should have checked my post...I meant ETCO2 readings.


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## irish_handgrenade (Jun 10, 2010)

end tidal CO2 measures the exchange of gasses, if you have CO poisoning then your body won't be making much CO2, so your end tidal will be off, but your SPO2 will show at 100% or whatever. Anyway you took my post out of context, I was correcting an error in what that other guy said " SPO2 is a representation of the exchange of gasses in the blood/lungs" and he was wrong.


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## MonkeySquasher (Jun 11, 2010)

irish_handgrenade said:


> Actually SPO2 is a representation or the percentage of available hemoglobin is bonded with O2 or CO. Endtidal capnography is a representation of gas exchange within the lungs/blood...




Ah, you are correct.  Well played.


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## Emevas (Jun 25, 2010)

CSLEMT said:


> Recently watched a Little League baseball game when a batter was hit by a fastball on the left ear side of helmet.
> 
> Batter immediately dropped...  he remained conscious.
> 
> ...



I'd go in, assess his level of conciousness, do some neuro tests to check for focal deficits.

ask him if he's having a hard time breathing, check the pulse, check his breathing (could be signs of a head injury (aka cushing triad)), like say he's a kid, and hes braddin along at a rate of 40, breathing at 10 a min, and his pressure is 190/110, not normal vits for a kid...

however, being new to this site, i live in canada, and work as an EMT in a metro service, many of our patients are fine... actually a LOT of our patients are fine, and just request to go to the hospital (for their sore knee from the fall they had 8 days ago :glare.

the fact that it was a baseball is a pretty low mechanism of injury, hitting the hard helmet may have just gave him a slight concussion, probably stunning him as he's never felt that before.

but if it was serious, rapid transport, IV, o2, monitor, basic EMT skills that should be done on every unwell patient.

yup, BLS seems like an intimidating job, but its the easiest thing you can imagine.

LOC - ABC's - Bleeding (stop bleeding!) - other injuries or signs of illness?(aka assessment) - treat based on your protocols.


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## Akulahawk (Jun 25, 2010)

CSLEMT said:


> Recently watched a Little League baseball game when a batter was hit by a fastball on the left ear side of helmet.
> 
> Batter immediately dropped...  he remained conscious.
> 
> ...


My comments to you, Emevas, inline, in red...


Emevas said:


> *I'd go in*, assess his level of consciousness, do some neuro tests to check for focal deficits.
> Under what authority are you making contact with the batter? The coach isn't requesting your assistance yet. What neuro tests do you do, when, and why?
> ask him if he's having a hard time breathing, check the pulse, check his breathing (could be signs of a head injury (aka cushing triad)), like say he's a kid, and hes braddin along at a rate of 40, breathing at 10 a min, and his pressure is 190/110, not normal vits for a kid...
> I doubt you'd see that severe of a head injury in a Little League player absent some congenital defect.
> ...


I have quite a bit of education in this area. Much of it I'm unable to use while on the job as a prehospital provider, due to scope of practice issues.


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## irish_handgrenade (Jun 26, 2010)

wow I was thinking the same thing... What kind of little leaguer gets a concussion from being hit by a pitch lol. 999,990 out of 1,000,000 times that happens the batter is ok. Sounds like you need to cool your jets a little bit there turbo. LOL almost every single kid that gets hit by a pitch falls down because they are a kid, plain and simple. Also, I didn't know IV O2 and monitor were BLS skills...?


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## LucidResq (Jun 26, 2010)

irish_handgrenade said:


> Also, I didn't know IV O2 and monitor were BLS skills...?



The person mentioned they are from Canada, where they have a different scope of practice. 

Out here in CO, with two classes post-EMT, an EMT-B can start IVs and do very basic monitoring. Can't treat any arrhythmias... the training is to properly set everything up and recognize arrhythmias.


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## Akulahawk (Jun 26, 2010)

Irish: The other wrinkle in this is, how many Paramedics have formal education in evaluating concussions, especially with respect to athletics? I know a few that do... a very, very few. Unfortunately, doing those evaluations and making the appropriate play/no-play decisions is outside any Paramedic Scope of Practice that I am aware of.


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## UsualSuspect147 (Jun 27, 2010)

clibb said:


> With the oxygen, that totally depends on your protocol. Where I did my ride-alongs, you had to put oxygen on nearly every patient. It was more of a courtesy then anything else.
> Do happen to know what her SP02 was at? That should be what  you would determine if the patient needed oxygen or not.



Yeah that's what I was going to post. The fact that her pupils were PERRL or not doesn't really matter... her SPo2 does. And I don't see why blood loss would require 15LPM at all. If anything a NRB tends to freak people out, especially children. NC is fine... but 6 is a little excessive for a NC, tends to dry out the nose and hinder more than help.


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