# BLS Support / Daily Scenario / #2 MVC



## Medic27 (Aug 17, 2017)

"Medic 27 please respond to an MVC roll-over crash, complainant states two vehicles were involved, Medic 28 and Engine 35 are responding."  

Medic 28 & Engine 35 are on scene, you are given the least critical patient. They expedite transport.

Your patient:
27 year old female / seat-belt 
Chief Complaint: Major headache, and crushing chest pain. Chest pain radiates into the neck.

Observations:
Small bump on the head, patient isn't fully there, however, patient responds to verbal commands and reflexes to pain. Patient has been protected with full-spinal precautions and is ready for transport. ALS is 15 minutes out so you decide to transport to the nearest ED.

Trauma assessment complete, chest bruising is present, head pain reveals upon inspection as small bump. No other injuries at this time.

GCS Scale - 11

HR: 122
BP: 100/72
RR: 23
O2 Sat: 93% with 100% O2 via non-rebreather 15L


Shortness of Breath (difficult taking deep breaths) , Muffled Heart Sounds, Jugular Vein Distension, Double Vision, Clear Breath Sounds.

BLS & ALS 

What are you treating for? Multiple things?
Why are you suspecting this?
Why did you elect with this line of treatment?

Good luck everybody, I tried to be more specific on this one.


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## EpiEMS (Aug 17, 2017)

My primary concern is not getting run over!






 .


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## GMCmedic (Aug 17, 2017)

EpiEMS said:


> My primary concern is not getting run over!
> 
> 
> 
> ...


That's not a 5 point break away. What if the tow mirrors a diesel truck with smoke stacks catches your vest? 


Oh and the patient has a head bleed and Cardiac tamponade.

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## Medic27 (Aug 17, 2017)

EpiEMS said:


> My primary concern is not getting run over!
> 
> 
> 
> ...


Yesss! Correct answer, 100%!


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## Medic27 (Aug 17, 2017)

GMCmedic said:


> That's not a 5 point break away. What if the tow mirrors a diesel truck with smoke stacks catches your vest?
> 
> 
> Oh and the patient has a head bleed and Cardiac tamponade.
> ...


Also correct, damn... Maybe I have to make these harder.  What is your treatment?


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## NysEms2117 (Aug 17, 2017)

Medic. Just so these threads don't take over the whole topic section you may want to make one thread and continue posting in there.


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## Medic27 (Aug 17, 2017)

NysEms2117 said:


> Medic. Just so these threads don't take over the whole topic section you may want to make one thread and continue posting in there.


I can do that if you would like. Not a problem.


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## DesertMedic66 (Aug 17, 2017)

So we have an altered patient who possibly has a brain bleed and a cardiac tamponade. I hope that the closest facility you are transporting to is also a trauma center..


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## GMCmedic (Aug 17, 2017)

Medic27 said:


> Also correct, damn... Maybe I have to make these harder.  What is your treatment?


Mostly supportive. She gets a NRB and a smooth ride to the trauma centet with lights and sirens. Preferably fairly close to the speed limit. 

I really wouldnt want to intubate unless I have too. 

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## VentMonkey (Aug 17, 2017)

NysEms2117 said:


> Medic. Just so these threads don't take over the whole topic section you may want to make one thread and continue posting in there.


Perhaps have the mods merge them, and put them in the scenarios section because they're, well, scenarios.


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## EpiEMS (Aug 17, 2017)

GMCmedic said:


> I really wouldnt want to intubate unless I have too.


Indication for intubation primarily being a decline in mental status?


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## VentMonkey (Aug 17, 2017)

EpiEMS said:


> Indication for intubation primarily being a decline in mental status?


Not necessarily for me, Ep. Obviously it depends on several factors such as how rapid and drastic the GCS has declined, how far we are from said trauma center, how well they're able to maintain their own airway/ we're able to maintain it for them with adequate oxygenation and ventilation and without having to move to aggressively invasive airway management techniques.

Many times if the patient can still converse fairly logically, even in the presence of an obvious closed head injury, it is so much more practical to allow the trauma team to obtain as close to an accurate initial GCS as they can upon our arrival at the ED, and their own neurological assessment, then they can induce for surgical repair and airway protection. Again, many ED attendings are not exactly thrilled with long-acting paralytic inductions for these reasons listed, even though we all know they will eventually wear off.


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## EpiEMS (Aug 17, 2017)

@VentMonkey Makes sense, thanks!


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## NysEms2117 (Aug 17, 2017)

VentMonkey said:


> Perhaps have the mods merge them, and put them in the scenarios section because they're, well, scenarios.


no can do. makes too much sense. not allowed


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## GMCmedic (Aug 17, 2017)

EpiEMS said:


> @VentMonkey Makes sense, thanks!


I'm more concerned with respiratory status, like @VentMonkey said, as long as she can maintain her own airway ill leave it alone. She needs things I can't offer. Her right ventricular filling will already be compromised, i dont really want to add more pressure.

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## VentMonkey (Aug 17, 2017)

GMCmedic said:


> Her right ventricular filling will already be compromised, i dont really want to add more pressure.


Right, so now which BLS provider on here can explain to _us_ the physiological changes behind such catastrophes and why?


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## Medic27 (Aug 17, 2017)

I am going to respond to my own scenario just for the practice..

I am going to keep in mind the patient isn't entirely there with me, make sure to keep the patient with me (awake) due to the head injury. If the SPO2 drops any lower I will switch to a BVM w/ 100% O2 @ 15L. Monitor vitals closely, call ahead to ED. Lights and sirens smooth transport. M27 inbound with a 27 year old patient involved in a MVC, GCS Scale 11, Vitals, O2 via BVM treatment, likely cardiac tamponade, possible head bleed,  ETA your facility 5.


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## EpiEMS (Aug 17, 2017)

@VentMonkey Well, if there is a shift in the mediastinum due to a pneumothorax, the vena cava could be compressed, so there isn't sufficient venous return to the heart? Perhaps? Unless you're thinking this is tamponade - which I suppose would affect both sides.


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## E tank (Aug 17, 2017)

EpiEMS said:


> @VentMonkey Well, if there is a shift in the mediastinum due to a pneumothorax, the vena cava could be compressed, so there isn't sufficient venous return to the heart? Perhaps? Unless you're thinking this is tamponade - which I suppose would affect both sides.



Here's a monkey wrench...If your patient has cardiac tamponade, taking a breath causes a drop in his cardiac output...and we can demonstrate that by measuring  a pulsus paradoxus....but, taking a breath causes the intrathoracic pressure to fall and venous return to rise...yet the cardiac output falls anyway....

Paralyze, intubate and mechanically intubate this person and you still have tamponade, but the pulsus paradoxus goes away...


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## Brandon O (Aug 17, 2017)

E tank said:


> Paralyze, intubate and mechanically intubate this person and you still have tamponade, but the pulsus paradoxus goes away...



Or reverses!


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## EpiEMS (Aug 17, 2017)

@E tank Sounds like the only urgent treatment is pericardiocentesis, at this point? Not that I can do that, of course.


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## Brandon O (Aug 17, 2017)

EpiEMS said:


> @E tank Sounds like the only urgent treatment is pericardiocentesis, at this point? Not that I can do that, of course.



Eh. Inopressors. But basically.


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## EpiEMS (Aug 17, 2017)

Brandon O said:


> Eh. Inopressors. But basically.


So the inopressors (e.g. dopamine) are just a temporizing measure, then?


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## Brandon O (Aug 17, 2017)

EpiEMS said:


> So the inopressors (e.g. dopamine) are just a temporizing measure, then?



Yea. Doesn't help much squeezing the heart/vessels if the heart's not filling.


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## Medic27 (Aug 17, 2017)

Is there anyone here who in their protocol/scope of practice can do a paracardiocentesis? I know it's very frowned upon in the prehospital setting depending on who you talk too... Just curious. Or @ Medical Director discretion if in a remote region?


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## E tank (Aug 17, 2017)

Brandon O said:


> Or reverses!



I've had it go both ways. If there are sufficient volume losses superimposed on the tamponade, you could see pulse pressure variation on inspiration with the ventilator, yes. 

I've had cases of isolated tamponade with no significant  ongoing losses or losses that have been replaced and the arterial waveform becomes uniform once I mechanically ventilated.


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## GMCmedic (Aug 17, 2017)

Medic27 said:


> Is there anyone here who in their protocol/scope of practice can do a paracardiocentesis? I know it's very frowned upon in the prehospital setting depending on who you talk too... Just curious. Or @ Medical Director discretion if in a remote region?


Its typically limited to HEMS

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## Medic27 (Aug 17, 2017)

GMCmedic said:


> Its typically limited to HEMS
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


Gotcha, that would make sense... I just wondered in terms of scopes, in Idaho I believe paramedics can use the skill if permitted by a medical director.


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## E tank (Aug 17, 2017)

EpiEMS said:


> So the inopressors (e.g. dopamine) are just a temporizing measure, then?


 
Epi or Norepi...remember that just like anything else, there are varying degrees of cardiac tamponade. These patients are not necessarily going to die right in front of you just because they are showing signs, especially if they're young. In that respect these drugs will be more or less helpful because there is such a variation in the way these folks present. It doesn't even have to be traumatic.

 Also remember that part of the reason for the fall in LV stroke volume is the filled RV pushing against the septal wall, further impeding  LV filling. So getting the RV to empty a little better with some epi theoretically gets more blood to the LV.


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## Brandon O (Aug 17, 2017)

E tank said:


> I've had it go both ways. If there are sufficient volume losses superimposed on the tamponade, you could see pulse pressure variation on inspiration with the ventilator, yes.
> 
> I've had cases of isolated tamponade with no significant  ongoing losses or losses that have been replaced and the arterial waveform becomes uniform once I mechanically ventilated.



Maybe due to smaller tidal volumes... wonder what it would look like if you cranked up the volumes to a liter or so. Most of our dynamic metrics of volume responsiveness (IVC collapsibility, pulse pressure/SV variability, etc) sometimes need a challenge of this kind of manifest on the vent.


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## agregularguy (Aug 17, 2017)

Medic27 said:


> Is there anyone here who in their protocol/scope of practice can do a paracardiocentesis? I know it's very frowned upon in the prehospital setting depending on who you talk too... Just curious. Or @ Medical Director discretion if in a remote region?



Only ground place I know of that can do it is Williamson County EMS-At least according to their website. I'll let another member who lives closer/works there chime in if it's actually done or not.

"Standing orders for field RSI, surgical/dual needle cricothyrotomy, field STEMI/Stroke activation, *pericardiocentesis*, induced hypothermia protocol, and an aggressive and compassionate analgesia and pain management protocol. "
https://www.wilco.org/Departments/EMS/Work-for-WCEMS


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## VFlutter (Aug 17, 2017)

E tank said:


> Also remember that part of the reason for the fall in LV stroke volume is the filled RV pushing against the septal wall, further impeding  LV filling. So getting the RV to empty a little better with some epi theoretically gets more blood to the LV.



Epi was usually our go to inopressor in tamponade, as well as massive PE, because of the RV squeeze. Also aggressive fluid resuscitation.



GMCmedic said:


> Its typically limited to HEMS
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk



It used to be in our protocols but has since been removed. I doubt there were many cases of true tamponade being treated. Usually more of a "Why not?" during traumatic arrests.  I think with Ultrasound becoming more common in HEMS it may make a come back.


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## GMCmedic (Aug 17, 2017)

Chase said:


> Epi was usually our go to inopressor in tamponade, as well as massive PE, because of the RV squeeze. Also aggressive fluid resuscitation.
> 
> 
> 
> It used to be in our protocols but has since been removed. I doubt there were many cases of true tamponade being treated. Usually more of a "Why not?" during traumatic arrests.  I think with Ultrasound becoming more common in HEMS it may make a come back.


I dont know that I have ever heard of it being done outside of a traumatic arrest or confirmed tamponade in the ER (our flight crews can work in the hospital). 

@Medic27. I'm pretty sure pericardiocentesis was common for ground services many years ago. I don't know the exact reason it went away, but I would bet money it's because its a skill that requires practice to be proficient and it likely didnt change patient outcomes. 

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## Medic27 (Aug 18, 2017)

GMCmedic said:


> I dont know that I have ever heard of it being done outside of a traumatic arrest or confirmed tamponade in the ER (our flight crews can work in the hospital).
> 
> @Medic27. I'm pretty sure pericardiocentesis was common for ground services many years ago. I don't know the exact reason it went away, but I would bet money it's because its a skill that requires practice to be proficient and it likely didnt change patient outcomes.
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


The primary reason for it going away to my knowledge was due to the rate of failure. If you go too far you puncture the heart...


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## GMCmedic (Aug 18, 2017)

Medic27 said:


> The primary reason for it going away to my knowledge was due to the rate of failure. If you go too far you puncture the heart...


Which goes back to proficiency

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## Medic27 (Aug 18, 2017)

BLS Scenario Scene #3) 8/18/2017


GMCmedic said:


> Which goes back to proficiency
> 
> Sent from my SAMSUNG-SM-G920A using Tapatalk


I see what you are going for with that statement, so in terms continuing this scenarios of the day... Should I keep in going in this thread? I think someone expressed their opinion about this dominating the BLS Discussion. Any ideas?


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## EpiEMS (Aug 18, 2017)

Medic27 said:


> BLS Scenario Scene #3) 8/18/2017



I certainly like the scenario of the day - perhaps pop it into the scenarios section.


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## Medic27 (Aug 18, 2017)

Scenario is now up and rolling, ALS/BLS 
https://emtlife.com/threads/basic-life-support-question-of-the-day-medic-27-3.46171/
Question #3, moved.


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## VentMonkey (Aug 18, 2017)

@Medic27 for the last time- you are missing a huge chunk of the "why's", and "how's", and that is something we cannot condense into countless threads. Understanding all of these issues, creating scenarios, and asking a bunch of ALS providers BLS scenarios is fine and all, but you cannot go from a mile to a marathon in a day.

You need to take some basic college-level A & P, gain some field experience, then start playing the "what ifs" game with your partners and peers. I believe it was @mgr22 who eluded to cracking open a paramedic textbook, which isn't a half bad idea, but from someone who has done this just a smidge longer than you and quite literally wasted some of his youth not taking many of the courses that would have put me ahead- you need them.

If you're having trouble landing a job because of where you live, and this career field is somewhat of an obsession for you, then move. You will find employment eventually, and again, all of this stuff you are picking people's brains about that you have learned about in EMT school, or that interests you, will begin to come together in _your_ own way.


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## RocketMedic (Aug 22, 2017)

Montgomery County Hospital District does perform field pericardiocentesis. However, it is a fairly rarely-performed intervention that they only perform in the context of a traumatic arrest or a classic cardiac tamponade- both of which are not super-common problems.

I personally believe it is a great idea. Sure, the numbers to support it really aren't there, but (at the risk of sounding like an uneducated schleb) these are not interventions performed for the lolz, they're last-ditch lifesaving salvage interventions being performed on the peri-arrest or arrested patient, and they're interventions with a solid and proven track record of success when applied both in the field and hospital. _Why not, _in other words? We know the alternative result. Properly-done interventions _might_ work and change that otherwise-certain outcome.


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## VFlutter (Aug 22, 2017)

RocketMedic said:


> and they're interventions with a solid and proven track record of success when applied both in the field and hospital.



I don't have the numbers but I do think there was a fairly high complication rate. In traumatic arrest it doesn't really matter but in peri-arrest it gets kind of tricky. You think there is a tamponade, go for it, then end up perforating the ventricle or causing iatrogenic tamponade when there wasn't one to being with then it's hard to justify unless you are sure they would have arrested otherwise. Complication rates are much lower with ultrasound guidance.


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## VentMonkey (Aug 22, 2017)

Both FP-C course instructors I sat in with said they had each done maybe one in their careers--respectively--none of which, IIRC, had a stellar outcome discharge-wise.

It is pretty much a last ditch effort in the field with, or without U/S. I was taught how to do one in a cadaver lab without U/S guidance within a matter of minutes; hardly a realistic scenario. 

The "skill" itself is not all that hard, it is the ramifications of such a skill that one needs to be prepared to deal with. Again, this is what separates the clinician from the technician.


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## RocketMedic (Aug 22, 2017)

Chase said:


> I don't have the numbers but I do think there was a fairly high complication rate. In traumatic arrest it doesn't really matter but in peri-arrest it gets kind of tricky. You think there is a tamponade, go for it, then end up perforating the ventricle or causing iatrogenic tamponade when there wasn't one to being with then it's hard to justify unless you are sure they would have arrested otherwise. Complication rates are much lower with ultrasound guidance.



Oh, if it's going to be done, I think it should be well-trained and US-guided. I do think it is good to have in the toolbox though.


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