BLS transport of ALS emergency???

[Akulahawk]

What if you take the patient off the oxygen and hes still at 93%? Thar would guide my treatment

And if he is, then ill just crank the NC to 6lpm or 10 lpm or even GASP! 15lpm. And if the patient continues to deteriorate and i start considering RSI, i dont have to interrupt supplemental oxygenation when i attempt to place the tube.

The last thing you want to do intubate this guy. This is one of the few times when you actually need 15L NRB and diesel. He has a confirmed pneumothorax. There is very little you can do in the field so get him to the hospital.

I'm pretty much with ERDoc on this. While I would be okay with seriously increasing the oxygen flow through the nasal cannula, I would first want to be certain that the nasal cannula is designed to handle the higher flow. Something else that struck my mind is that if you have the ability to intubate via RSI, then you also have the ability to probably do a needle decompression. This patient has a spontaneous pneumothorax and if you switch to PPV, effectively make the problem worse faster.

To me, the fact that patient is on 15 L and only has an SPO2 of 93% means that I really don't need to get a room air saturation. He's probably also working to breathe a bit, I would probably want to check for tracheal deviation and if I find it, then this guy fits needle decompression criteria. I am, of course, approaching this from an ALS perspective. Being that the transport crew is BLS, and 6 miles away from the ED, I would rather go with the BLS crew transport that is on hand right now that wait more time for an ALS crew to arrive. The ED is already aware of the impending arrival of the patient and is probably ready to receive him and perform an immediate and emergent chest tube placement for chest decompression. Even if the patient compensates in route, the arrival time is very short and the ED is ready, they can again do an emergent chest decompression.

 

[CANMAN]

What if you take the patient off the oxygen and hes still at 93%? Thar would guide my treatment

And if he is, then ill just crank the NC to 6lpm or 10 lpm or even GASP! 15lpm. And if the patient continues to deteriorate and i start considering RSI, i dont have to interrupt supplemental oxygenation when i attempt to place the tube.

Wow... Do you honestly believe that given the scenario you can take this guy off 100% NRM and his sats might stay at 93% ?

 

[systemet]

That would be some awesome shunt physiology.

 

[Bullets]

I'm pretty much with ERDoc on this. While I would be okay with seriously increasing the oxygen flow through the nasal cannula, I would first want to be certain that the nasal cannula is designed to handle the higher flow. Something else that struck my mind is that if you have the ability to intubate via RSI, then you also have the ability to probably do a needle decompression. This patient has a spontaneous pneumothorax and if you switch to PPV, effectively make the problem worse faster.

True, i forgot what subforum im in.

Wow... Do you honestly believe that given the scenario you can take this guy off 100% NRM and his sats might stay at 93% ?

Ive seen functional hypoxics at like 84%, so ill believe anything at this point.

 

[ERDoc]

Ive seen functional hypoxics at like 84%, so ill believe anything at this point.

They have probably lived there for a while and their body has adapted. In this scenario we have someone with a relatively acute onset so their body will not like the situation and will not be able to compensate for very long.

 

[Akulahawk]

Ive seen functional hypoxics at like 84%, so ill believe anything at this point.

They have probably lived there for a while and their body has adapted. In this scenario we have someone with a relatively acute onset so their body will not like the situation and will not be able to compensate for very long.

If you've been in healthcare for any appreciable amount of time, you'll see those people that are well-adapted to living with their SpO2 level in the mid-80's and doing quite well. I've seen them too, not many, but I've seen them. However, I have yet to see a relatively young person do all that well when their SpO2 is in the mid-80's and they're not acclimated to being so hypoxic. I suspect that ERDoc has seen more of these than I have.

 

[ERDoc]

Other than kids with congenital issues, I can't think of anyone of a relatively young age I have ever seen that has tolerated a pulse ox in the 80s very well.

 

[Akulahawk]

Other than kids with congenital issues, I can't think of anyone of a relatively young age I have ever seen that has tolerated a pulse ox in the 80s very well.

There ya have it folks... ERDoc, thanks for posting that. I suspected that was the case.

 

[evantheEMT]

So you were nervous about the call and wanted als? Sometimes you do calls out of your comfort zones. Monitor the pts vitals and abc's atleast the hospital wasn't too far away. Also, if you're in the back with the pt you have the right to either have the emt respond or not unless the medic/supervisor is with you.

 

[MackTheKnife]

On the topic of danger of inserting a needle, while probably more risky and bearing a higher rate of complications than most other procedures, if done right, needle thoracentesis is still relatively safe. The reason it is drilled to go along the top of rib is to avoid the neurovascular bundle. The military trains soldiers in its CLS class to do needle thoracentesis within a few hours (on that specific skill). They do a large number of them, as tension pneumo was at one time responsible for killing 33% of soldiers dying of preventable causes. And yet, we haven't heard of a massive number of complications for such a high reward procedure.

From your posts on here, it seems as though you were not looking for others opinions, but rather affirmation of your thoughts, and trying to dismiss any dissenting opinions.

We teach TP can develop within 10-20 minutes in the military. We also teach that a needle decompression, even done inadvertently, does little to no harm. And yes, you go over the rib, not under. We carry 14ga needles for chest taps in our blowout kits.

 

[NYBLS]

So you were nervous about the call and wanted als? Sometimes you do calls out of your comfort zones. Monitor the pts vitals and abc's atleast the hospital wasn't too far away. Also, if you're in the back with the pt you have the right to either have the emt respond or not unless the medic/supervisor is with you.

Monitor the ABCs? This patient already has a failure right in B that has a high potential for required correction in the next few minutes.

 

[Doczilla]

A known ptx with a sat of 93% in 15L, that seems pretty ominous to me. Even if it is a short ride, I would rather see this guy go with a medic. There is a potentially life threatening condition that a medic can actually do something about. Needle decompression is not dangerous by any means as long as you know what you are doing. If there was no ALS present on the scene then I would say diesel is the best treatment but why not have that person who can do something in the ambulance in case it is needed.

OP, keep in mind that not all pneumos become tension pneumos. Some people can walk around for days/weeks with a ptx and be fine.

This. This may not be the most popular opinion here, but shortness of breath that worsens in the presence of a known or suspected (ANY chest trauma, including blunt, penetrating, or barotrauma) pneumothorax is enough to buy a decompression.

Too often I see people rationalizing that the patient needs to be in extremis to pop someone's chest; (JVD, tracheal deviation or other signs of mediastinal shift), and this is downright wrong. That's like witholding treatment for a STEMI until they code the first time.

If he's symptomatic, he needs to be treated. This isn't any different than treating an arrhythmia, heat illness, or sepsis; but since it involves putting a hole in someone, people freak out.

 

[Doczilla]

1. If you aren't comfortable with taking a patient then you need to speak up.

2. Thoracentesis is not done blind and is not that difficult if you have the training, you just need the balls to do it, and hen done correctly is not HIGHLY dangerous.

3. I vote No supervisor was not wrong, but if BLS wasn't comfortable he (or she) should have done a more thorough handoff.

Thoracentesis isn't done blind? God, don't tell me they're using ultrasounds for that too nowadays. They're practically using them for digital blocks anymore.

Which is funny, because every time I see a chest tube done, (including the ones I've performed), that was pretty much as blind as a procedure can get. How ironic that a (comparatively) little needle needs guidance. I'm calling risk adversity on this one.

 

[TransportJockey]

Thoracentesis isn't done blind? God, don't tell me they're using ultrasounds for that too nowadays. They're practically using them for digital blocks anymore.

Which is funny, because every time I see a chest tube done, (including the ones I've performed), that was pretty much as blind as a procedure can get. How ironic that a (comparatively) little needle needs guidance. I'm calling risk adversity on this one.

I wonder if he's confusing it with pericardiocentesis? Although the one of those I've done in the field was landmark only, no ultrasound guided.

 

[Doczilla]

I wonder if he's confusing it with pericardiocentesis? Although the one of those I've done in the field was landmark only, no ultrasound guided.

Yeah, even in tintinalli, blind pericardiocentesis is still a thing, just not a very "popular" thing. But then again, they've got surgeons to do a cardiac window and stuff like that at the hospital.

Whenever it comes up in the field, it always seems like a hail mary, so the risk/reward on a trauma arrest isnt thst big of a deal.

The only time I can think of as far as not popping someone's chest "blind", is using a portable US to confirm a pneumo before I made the decision to do it, but that's about it.

 

[Carlos Danger]

Which is funny, because every time I see a chest tube done, (including the ones I've performed), that was pretty much as blind as a procedure can get. How ironic that a (comparatively) little needle needs guidance. I'm calling risk adversity on this one.

Reducing risk isn't a bad thing.

 

[Doczilla]

Reducing risk isn't a bad thing.

Sure, but reducing risk for the sake of reducing risk can interfere with good clinical decision making. There is literally nothing that we do that is risk free.