Cardiac monitoring

[Bieber]

First call, BLS; no monitor, no IV. Just package and take to the hospital.

Second call, ALS; 3-lead (12-lead as well if age or complaints are suggestive of possible cardiac issues prior to or following the incident) and IV.

EDIT: Actually, realistically speaking, if I was less than five minutes away from the hospital, this stuff PROBABLY wouldn't get done. Maybe the monitor, probably not the IV. Ideally, it should, but when you're that close it would be pushing it.

 

[medicdan]

Heck, if I get an MVC in the area I work, we'll spend more time waiting on triage than in transport. Perhaps we should attach the monitor then.
Kidding.

 

[Dominion]

In my system:

Patient 1 would go BLS probably unless there was a medic on the truck.

Patient 2 would be medic with lock, monitor and standard assessment. I would also activate the trauma team.

 

[johnrsemt]

What is wrong with continuing your patient workup while waiting in Triage? If you have a short transport and have 15 min (or longer) wait at ED for a bed, continue to work up patient and check out patient.
We had a medic crew that had a 20 minute wait for a bed; patient was talking to Nurse at Triage and was dead when he was put on the bed. crew didn't notice that patient died. Oops

 

[boingo]

I wouldn't work up the first pt, I would the second. I tend to place the monitor on ALS trauma patients, I find VS changes can be picked up upon quicker if I have a visual display of HR. Plenty of my peers do not routinely do this, to each his/her own.

I do have an interesting EKG taken on a pt w a GSW to the L chest that shows 5 mm ST elevation in II and III, pretty good evidence of cardiac injury, no?

 

[CANMAN]

Tom with all due respect what is your rationale at ruling out cardiac monitoring on a patient involved in a major trauma? We aren't talking about 15 and R 12 leads here. talking about simple 3-5 lead monitor.

This is my point, you guys aren't interested in doing a 12 lead to assess for the previous injuries I stated in my post. I would like someone to state their case as far as exactly what they are looking for when applying the monitor to these said patients......What is a 4 lead going to show you on both of these patients that a good set of vitals and a radial pulse check cannot???

Also I don't think anyone has a BONER for the GCS scale, it is just the most widely utilized and understood neuro assessment tool that I know of. GCS is one of the most important findings on a baseline trauma line consult most decent trauma center's are concerned about. I guess places like Johns Hopkins and Shock Trauma in Baltimore are doing it all wrong??? If you think GCS only tells you the pt. is alert, can follow commands, etc then you need to brush up on it. A pt. is a uncal herniation's GCS is going to obviously be vastly different then a pt. with a simple altered LOC, and a correct GCS scale number paints a pretty good picture along with other verbal assessment findings to both trauma and neuro docs....

 

[reaper]

Actually our trauma docs want a trauma score, which is a combo of GCS and vitals. GCS alone cannot properly provide that.

I can have an AMS diabetic with a GCS of 3. I can have an unresponsive trauma pt with a GCS of 3. I can have a body that has been dead for a year, with a GCS of 3. This is where they are finding the flaws and moving away from GCS for neuro alone.

 

[sir.shocksalot]

In my system:

Patient 1 would go BLS probably unless there was a medic on the truck.

Patient 2 would be medic with lock, monitor and standard assessment. I would also activate the trauma team.

So your system activates the trauma team based on MOI? Several studies have pretty well shown that MOI doesn't always correlate to actual injuries, it just suggests where they might be.

I would not place either pt on the monitor. Unless there was some hx from the pt that there was a cardiac event prior to the crash I don't see monitoring as necessary. I also am rather surprised that some of you would monitor a rhythm before starting an IV on a trauma pt. Also why isnt anyone suspecting a concussion as the cause of his unconsciousness PTA.

Also its worth noting that the 3-lead tells you nothing other than rhythm, and as others have said unless there is some cardiac hx chances are it's NSR. If you are going to work up any pt as cardiac than a 12-lead has to be done.

Every pt is different and I really detest blanket treatments of IV, O2, monitor. Pt's rarely fit the molds of protocols.

 

[8jimi8]

This is my point, you guys aren't interested in doing a 12 lead to assess for the previous injuries I stated in my post. I would like someone to state their case as far as exactly what they are looking for when applying the monitor to these said patients......What is a 4 lead going to show you on both of these patients that a good set of vitals and a radial pulse check cannot???

Also I don't think anyone has a BONER for the GCS scale, it is just the most widely utilized and understood neuro assessment tool that I know of. GCS is one of the most important findings on a baseline trauma line consult most decent trauma center's are concerned about. I guess places like Johns Hopkins and Shock Trauma in Baltimore are doing it all wrong??? If you think GCS only tells you the pt. is alert, can follow commands, etc then you need to brush up on it. A pt. is a uncal herniation's GCS is going to obviously be vastly different then a pt. with a simple altered LOC, and a correct GCS scale number paints a pretty good picture along with other verbal assessment findings to both trauma and neuro docs....

Do you fly with your hand on their radial or carotid pulse? You may actually SEE a heart rate trend. Sure a pulse oximeter will give you a visual on the heart beat, but I feel more comfortable seeing a rhythm strip than something that could have a variable waveform.

What was that old example of the dead guy getting >8 on a GSC? i can't remember the exact score.. but the guy was DEAD.

I work in a trauma center and we don't use GCS except as the most minute of fleeting assessments.

 

[usalsfyre]

GCS is considered a rather blunt tool by many people for neuro assessment. As for well understood, give a patient with anything lower than a 14 to five different providers and see how many scores you get.

 

[usalsfyre]

First patient, a GOOD physical exam prior to transport. Assuming negative, BLS

Second patient, full workup including monitor, not delaying transport to do so. Activate trauma team if physical exam results warrant it.

Like 8jimi8 I want to be able to trend things real time, not every 5 or so minutes when I take a pulse.

 

[8jimi8]

Thanks US, i was beginning to feel ignorant and stitious (not superstitious, just a little stitious)

 

[usalsfyre]

So your system activates the trauma team based on MOI? Several studies have pretty well shown that MOI doesn't always correlate to actual injuries, it just suggests where they might be.

Heretic! The Church of R Adams Cowley sentences you to 15 trauma activations and 5 air medical transports based in MOI as penace.

I would not place either pt on the monitor. Unless there was some hx from the pt that there was a cardiac event prior to the crash I don't see monitoring as necessary. I also am rather surprised that some of you would monitor a rhythm before starting an IV on a trauma pt. Also why isnt anyone suspecting a concussion as the cause of his unconsciousness PTA.

Concussion is my #1 differential. Epidural hematoma via a temporal artery injury is #2. If your not familiar with epidural hematoma, it's a bad mofo that often disguises itself as a concussion if your not doing good assessments.

I've monitored lots of patients and not initiated access. It's about watching what's going on more closely

Also its worth noting that the 3-lead tells you nothing other than rhythm, and as others have said unless there is some cardiac hx chances are it's NSR. If you are going to work up any pt as cardiac than a 12-lead has to be done.

Cardiac contusion often presents with dysrhythmia in addition to other signs of poor perfusion. Probably a useful assessment tool, right? In addition I can trend a HR better off a strip than anything else.

Every pt is different and I really detest blanket treatments of IV, O2, monitor. Pt's rarely fit the molds of protocols.

I understand the blanket treatment hate. But you seem to go so far to the extreme the OTHER direction as to almost seem lazy. This stuff is useful. A monitor is a useful ongoing assessment tool and it's very hard to do much of anything (like pain management) besides transport without access. Agree with you about the O2 though. Unless they're hypoxicly hypoxic, O2s pretty pointless.

 

[rhan101277]

Every person that shows up in the ER doesn't get a 4 lead.

I think it is good not to throw the book at everybody.

If you have a simple slip/trip, no weakness before hand, no diabetes hx, no LOC. Are you going to put them on cardiac monitor? A glucose check would be considered just being extra cautious. A cardiac monitor would not be warranted and it costs the pt when you do un-necessary procedures.

If it is needed by all means then do so. If you do it anyhow I think it is cookbook medicine.

 

[8jimi8]

In the hospital we have the benefit of being able to have a patient on the monitor without charging them for it. Maybe its included in the room charge.

I have the benefit of caring for patients and not even knowing if they are funded or unfunded. I do everything i deem necessary for the standard of care and If I think something needs to be done I call the physician and ask them for the order. I rarely get turned down and often get exactly what I want.

In my world and ecg strip is a vital sign. And no one has given any rationale as to why a VEHICLE vs PED (sorry i originally read it as pediatric) is not put on the monitor. USALS gave several key pathologies that could result from such an event.

 

[Bieber]

So your system activates the trauma team based on MOI? Several studies have pretty well shown that MOI doesn't always correlate to actual injuries, it just suggests where they might be.

Mine does. And there's no clause for paramedic discretion--in order to downgrade or upgrade, we have to call the hospital. I don't like it either, but I'm not really in a position to change things.

Every pt is different and I really detest blanket treatments of IV, O2, monitor. Pt's rarely fit the molds of protocols.

I completely agree.

 

[rhan101277]

A bad epidural hematoma should cause unequal pupils and if bad enough cushings triad should be starting to show.

 

[8jimi8]

A bad epidural hematoma should cause unequal pupils and if bad enough cushings triad should be starting to show.

cushings triad is a late sign.

 

[usalsfyre]

Epidural hematoma sometimes (around 20% of cases) presents with an initial brief loss of consciousness immediately post-injury (i.e. right after he got mowed over on the bike), followed by a lucid period which then deteriorates into unconsciousness later. If it deteriorates into unconsciousness mortality is appx 20%. More than one provider has been too complacent in assessment and chalked this injury to concussion.

Loss of consciousness should give any provider a very high index of suspicion for serious head injury.

 

[reaper]

Also need to remember that there are different grade concussions.
Epidurals do not always present with unequal pupils and cushings is a very late sign.

Do your assessment, Look at ALL the vitals, treat as needed!