Cardiac monitoring

[sir.shocksalot]

I don't like it either, but I'm not really in a position to change things.

I hear you, I know I have other equally annoying protocols. I swear every time I have to get out of the rig so we can back up 2 feet makes me want to throw things

Usalfyre, I hope you weren't assuming I wasn't thinking of those things, I was just throwing out an example . Kinda like the the when you hear hooves think of horses, not centaurs. In these trauma pts unconsciousness is far more likely to be from a head impact than some weird cardiac rhythm.

Also I completely agree about considering head bleed stuff, or even cardiac contusion stuff, if there is some indication based on MOI that such injuries may exist. A cyclist flung over a car hood probably won't have much blunt chest trauma depending on how they hit. Where as a dude that hit the steering wheel might have some pulmonary or cardiac contusions.

I think a lot of people have forgotten the transport time. 5 minutes really isn't a tremendous amount of time, but in 5 minutes with a trauma pt I have other things to do than place them on the monitor to confirm that its NSR. Assume that you start a line and do a secondary assessment before you reach for the monitor, you would realistically only have, like, 3 minutes of strip. That doesn't seem like much time to really have a decent trend in HR. Heck even 5 minutes isn't much.

It's not about being lazy, it's about time management. I'm guessing you come from a system that has fairly long transports? I work in a system where transport times can be as low as 30 seconds to drive across the street. I have to walk into the ER with the same assessment and the same critical interventions (such as a line, meds, tube, you name it) but all of it must be done in less than 5 minutes. I'm not saying one is better (I think long transports require smarter medics), it's just that sometimes I have to skip doing certain secondary things (like a monitor) to get a good assessment done and make sure I'm not missing any occult life threats.

 

[usalsfyre]

I hear you, I know I have other equally annoying protocols. I swear every time I have to get out of the rig so we can back up 2 feet makes me want to throw things

Usalfyre, I hope you weren't assuming I wasn't thinking of those things, I was just throwing out an example . Kinda like the the when you hear hooves think of horses, not centaurs. In these trauma pts unconsciousness is far more likely to be from a head impact than some weird cardiac rhythm.

Also I completely agree about considering head bleed stuff, or even cardiac contusion stuff, if there is some indication based on MOI that such injuries may exist. A cyclist flung over a car hood probably won't have much blunt chest trauma depending on how they hit. Where as a dude that hit the steering wheel might have some pulmonary or cardiac contusions.

I think a lot of people have forgotten the transport time. 5 minutes really isn't a tremendous amount of time, but in 5 minutes with a trauma pt I have other things to do than place them on the monitor to confirm that its NSR. Assume that you start a line and do a secondary assessment before you reach for the monitor, you would realistically only have, like, 3 minutes of strip. That doesn't seem like much time to really have a decent trend in HR. Heck even 5 minutes isn't much.

It's not about being lazy, it's about time management. I'm guessing you come from a system that has fairly long transports? I work in a system where transport times can be as low as 30 seconds to drive across the street. I have to walk into the ER with the same assessment and the same critical interventions (such as a line, meds, tube, you name it) but all of it must be done in less than 5 minutes. I'm not saying one is better (I think long transports require smarter medics), it's just that sometimes I have to skip doing certain secondary things (like a monitor) to get a good assessment done and make sure I'm not missing any occult life threats.

I see what your saying, I think it's a semantics difference. I consider the cardiac monitor less of an intervention and more of an assessment tool, one that helps me in making the correct transport decision (local ED in town that's 30sec-5 minutes away, or trauma/stroke/STEMI centers 25-30 minutes away in the "big city"). As such it gets applied pretty quickly. Usually before lines, ect. All of this is stuff that I pretty well consider can wait till the ED if I'm going around the corner, the nurses may not like it, but they'll live.

If I'm doing airway management I'm usually planning on adding between 5 and 10 minutes to a scene time, and you won't see me tube with out monitoring devices applied. It's just to high-risk to wing it.

I'm good with the horses, I LIKE horses, as zebras and centaurs have an annoying habit of biting you in the :censored: . In my personal practice I just put a lot more stock in good assessment than intervention.

 

[TomB]

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.

With all due respect, what is your rationale at ruling out bilateral traction splinting?

 

[8jimi8]

With all due respect, what is your rationale at ruling out bilateral traction splinting?

Wow, Tom unwilling to teach this morning. No biggie, just a surprise.

 

[vquintessence]

Eh, you more or less got an answer. You wouldn't blindly apply traction splints just because it's a trauma, just as you shouldn't blindly apply cardiac monitoring just because it's a trauma. It's akin to the teacher provoking a thought so the student can answer their own question.

 

[8jimi8]

Eh, you more or less got an answer. You wouldn't blindly apply traction splints just because it's a trauma, just as you shouldn't blindly apply cardiac monitoring just because it's a trauma. It's akin to the teacher provoking a thought so the student can answer their own question.

The question being that we've already discussed pathologies that monitoring would readily identify, post vehicle vs ped.

It isn't like arrhythmias are a consistent and contiguous injury like a femur fracture would be.

You don't go in and out of femur fracture. You don't have a "normal sinus femur fracture" that suddenly becomes "bradycardic femur fracture" or "superventricular femur fracture." Your femur fracture doesn't really change from a greenstick fracture to a comminuted fracture.

Say your patient goes into SVT after you check their pulse, which was previously normal. Is it possible that because the patient doesn't present in a decompensated state that you may do a q15 minute vital recheck versus a q 5 minute vital check? What if the patient threw a PE from their bilateral femur fractures? Would they warrant a monitor IF they had bilateral femur fractures? Wouldn't you want them on the monitor so that you might notice the tachycardic trends as they bleed out 8 liters into BLE?

Just sayin. I can assess pretty physically well for a fracture, ruling out bilateral traction splints.

A radial pulse does not tell me what your rhythm is.

Hey maybe i'm gonna be a cookbook medic... But it seems like the standard of care to me. Are you a standard of care (general you) medic or are you a MINIMUM standard of care medic? I know they test at NREMT to the MINIMUM...

 

[Dominion]

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.

Yea my system activates trauma team on MOI alone. This is how it goes in my system, you bring a trauma patient in, you've already activated the trauma team based on MOI and loc prior to your arrival. You roll into trauma room and the residents with the attendants overlooking will do a quick assessment and decide if the patient needs to be seen or if they can be seen in triage.

Now if I DON'T activate the system myself, when I roll in and tell the nurse there that he was biking, struck by a car at approx 25mph, loc prior to arrival, now alert and orients. She will go ahead and activate the trauma team and we go through the above process.

It's not perfect, but we work with it.

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.

We have discretion to activate or not, it just gets reversed sometimes the second we get to the hospital. In addition we do get a chance to NOT go if we call ahead. Generally if I had patient two I would make the call something like "We have a <x> year old male, riding a bike, struck by a car, thrown <x> feet, positive loc prior to our arrival, currently conscious, alert, and oriented. Vitals stable......" at that point if you think he really needs the trauma room I just say "I'll see you in the trauma room in x minutes" if I don't think he needs it and I want to forgo it before I arrive I'll say something like "do you want to see this patient in trauma room or am I ok for triage?".

Sorry if that explanation doesn't make sense ;P.

 

[usalsfyre]

Eh, you more or less got an answer. You wouldn't blindly apply traction splints just because it's a trauma, just as you shouldn't blindly apply cardiac monitoring just because it's a trauma. It's akin to the teacher provoking a thought so the student can answer their own question.

Why do so many think of cardiac monitoring as an intervention (which it's not) instead of an assessment? Maybe because that's the way EMS bills it?

What your advocating is not only not applying bilateral traction splints, but not even looking at the legs.

 

[Shishkabob]

Eh, you more or less got an answer. You wouldn't blindly apply traction splints just because it's a trauma, just as you shouldn't blindly apply cardiac monitoring just because it's a trauma. It's akin to the teacher provoking a thought so the student can answer their own question.

Femurs are their own "system". If you break your finger, that doesn't mean your legs will be hurt.


However, the cardiovascular system is not independent. If you're involved in trauma, there's a VERY good chance your heart is doing something.

 

[Dominion]

Femurs are their own "system". If you break your finger, that doesn't mean your legs will be hurt.


However, the cardiovascular system is not independent. If you're involved in trauma, there's a VERY good chance your heart is doing something.

This is part of my ALS assessment for any trauma I go on. That's part of the tiered system I'm in. Our BLS crews are very good and we have very liberal BLS protocols. I tend to get canceled on many different calls, so when I do go a cardiac monitor is just ONE assessment I do. I may not keep them on it, I may take it off when we arrive at the ER, but it is part of what I do while I"m with that patient. We also typically have longer transport times (10-20+ minutes) depending on where we're coming from.

 

[8jimi8]

This is part of my ALS assessment for any trauma I go on. That's part of the tiered system I'm in. Our BLS crews are very good and we have very liberal BLS protocols. I tend to get canceled on many different calls, so when I do go a cardiac monitor is just ONE assessment I do. I may not keep them on it, I may take it off when we arrive at the ER, but it is part of what I do while I"m with that patient. We also typically have longer transport times (10-20+ minutes) depending on where we're coming from.

Exactly, its a tool, just like a sphygmomanometer.

 

[Shishkabob]

Exactly, its a tool, just like a sphygmomanometer.

Us uneducated EMS folk say "Bloodpressure cuff"

 

[Dominion]

Us uneducated EMS folk say "Bloodpressure cuff"

I usually just say that squeezy thing attached to the monitor. h34r:

 

[jjesusfreak01]

Us uneducated EMS folk say "Bloodpressure cuff"

Just make it bloodpressurecuff. Now you know German.

 

[Shishkabob]

Just make it bloodpressurecuff. Now you know German.

I ALREADY know German.


Was machst du in deiner freizheit? Das ist duff.

 

[JPINFV]

Just make it bloodpressurecuff. Now you know German.

Just before the final exam in my EMT class, being the smart donkey I am I asked if a sphygmomanometer was going to be on the final and about half the class turned white.

 

[MasterIntubator]

I ALREADY know German.


Was machst du in deiner freizheit? Das ist duff.

Es ist eigentlich "Freizeit". Haben sie auch dumm, anstelle von duff?


We have protocols stating that an ECG will be done if any ALS proceedure is being done. Does it always get done? Nope. Good sound judgement should help guide ya.

 

[8jimi8]

Es ist eigentlich "Freizeit". Haben sie auch dumm, anstelle von duff?


We have protocols stating that an ECG will be done if any ALS proceedure is being done. Does it always get done? Nope. Good sound judgement should help guide ya.

And would you monitor either of these patients?

 

[Shishkabob]

Es ist eigentlich "Freizeit". Haben sie auch dumm, anstelle von duff?

Meh, kann ich nicht buchstabieren. Duff ist was wir in den Jahren meines Deutsch unterrichtet. Es hat vier Jahren auch.

My syntax will always be a bit off



Really, no reason to NOT have a strip on these people. Takes what, 15 seconds to put on the electrodes? If you need a line THAT badly, just do an IO.

 

[18G]

Honestly, with a 5min ETA why **** around ne longer then you really have to? Just load and go. Load and go will be the most important intervention you will give either of these patients in the absence of life-threatening, need corrected right now problems.

I had an MVC patient the other day that was literally 2mins from the hospital on the same street. He had a cardiac hx and was having anxiety and chest discomfort suspected to be from seatbelt. He got a cardiac monitor and 12-lead and right as the 12-lead was done we were backing in. I wasn't gonna spend extra time onscene asking 20 million questions, starting an IV, etc. when I could have this patient in the ED where he really needed to be.

Point being... regardless of ETA it takes very little time to throw electrodes on. But at the same time with a young patient, no PMH, and <5min ETA, the monitor really isnt a big deal in my opinion.

And if the radial pulse check correlates with the rate display on the pulse ox and patient is perfusing well, then I would trust the pulse ox in a stable patient for the short amount of time as described.

Everyone has their own thought and decision making process. The common thing to do is O2, IV, monitor, vitals... hmmm... really? We all know what the research says about everyone getting O2 so we can take that out. Does everyone really need an IV? Really? The same can be said about the monitor. Yes, its good to have it on for trauma patients to monitor rate and for ectopy but I certainly would not hammer someone for not applying it if they were busy doing an assessment or tending to actual patient injuries with a less than 5min ETA.