BLS Support / Daily Scenario / #2 MVC

What is your primary concern?

  • Head Pain

    Votes: 0 0.0%
  • Patent Airway

    Votes: 6 66.7%
  • Chest Pain

    Votes: 3 33.3%
  • Abdominal Pain

    Votes: 0 0.0%

  • Total voters
    9

EpiEMS

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

Brandon O

Puzzled by facies
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@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.
 

EpiEMS

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OP
Medic27

Medic27

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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?
 

E tank

Caution: Paralyzing Agent
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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.
 

GMCmedic

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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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OP
Medic27

Medic27

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Its typically limited to HEMS

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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.
 

E tank

Caution: Paralyzing Agent
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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.
 

Brandon O

Puzzled by facies
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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.
 

agregularguy

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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
 

VFlutter

Flight Nurse
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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.

Its typically limited to HEMS

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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.
 

GMCmedic

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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

Medic27

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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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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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Medic27

Medic27

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BLS Scenario Scene #3) 8/18/2017
Which goes back to proficiency

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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?
 

EpiEMS

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BLS Scenario Scene #3) 8/18/2017
I certainly like the scenario of the day - perhaps pop it into the scenarios section.
 

VentMonkey

Family Guy
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@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.
 

RocketMedic

Californian, Lost in Texas
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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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