Cardiac monitoring

[rhan101277]

I wanted to get some feedback on how many folks decide to for go cardiac monitoring. In the following two scenarios you are less than 5 minutes from the ER.

This is limited to these two specific scenarios only.

You have a ped vs car less than 5mph. AAOx3, pulse is regular, strong.

You have a bicycle vs car 25mph. Initially unresponsive, then minutes after is responsive and AAOx3. Pulse is regular, strong.

In both cases you decide to simply monitor the heart rate with pulse oximetry and occasional pulse checks at wrist.

I know it doesn't take long to put them on, but when you don't have much time and other things need accomplishing and are more important, it doesn't make since for me to put them on.

If any of the above scenarios resulted in difficulty finding pulses, patient not alert or irregular heart rate noticed on palpation, cardiac monitoring would be applied

Any feedback?

 

[8jimi8]

Dont you have a partner who can apply electrodes while you all are packaging? Monitoring doesn't take that long and you might miss important vital signs that only monitoring would provide.

how long does it take to put 3-5 leads on? you need to expose the abdomen on mvcs anyway... why not throw the monitor on at the same time?

 

[Mobey]

Honestly man, cardiac strip has become part of my routine vitals.

It is not very often I don't put one on.


One thing I teach my students is EVERY sick patients get 02, IV, cardiac monitor.

So to directly answer your question.... Yes both the above patients would have a monitor. Chances are, if I suspect chest trauma (which I already do based on height of peds vs hood) they would both get 12 leads too.

 

[firecoins]

its required here.

 

[rhan101277]

One thing I teach my students is EVERY sick patients get 02, IV, cardiac monitor.

I know this, I guess I got in to much of a hurry to get off scene. I always do this, don't know what I was thinking this time.

 

[mc400]

If you are running the PT in BLS then I do not think it is that big of a deal, getting the PT to definitive care is the big issue, plus if you find an irregularity you wont have time to treat it.

With that said I get at least a 4 lead on pretty much everyone. Also pt may not need an IV if you have an extra medic yeas but rapid bls transport is key. Rapid assesment, expose/package, load and go. Secondary assesment E/R. Its all case dependant though.

I am never 5 minutes from a hospital though. About 12 min is the closest from any area in my district.

 

[TomB]

I see no indications for cardiac monitoring in either scenario.

 

[MrBrown]

Maybe, nothing more than a 3 lead to identify rate and rhythm tho

 

[JPINFV]

My biggest concern is the use of a pulse ox to measure the pulse. Does the monitor show a waveform or how are you confirming that the pulse ox is accurate?

 

[CANMAN]

Honestly man, cardiac strip has become part of my routine vitals.

It is not very often I don't put one on.


One thing I teach my students is EVERY sick patients get 02, IV, cardiac monitor.

So to directly answer your question.... Yes both the above patients would have a monitor. Chances are, if I suspect chest trauma (which I already do based on height of peds vs hood) they would both get 12 leads too.

Routine vitals huh, you must work in a very slow jurisdiction. So a nosebleed gets a 4 lead strip??

I have to agree with TomB on this one. I don't see a need for either patient to be cardiac monitored. If both patients have normotensive vital signs to include pulse rate, and you palpate a regular pulse I think its VERY safe to say they are both in NSR. 12 lead for both patients????? I think is way overkill. Whats a 12 lead going to show you that is going to be something you can correct on scene? Nothing, therefore you have just wasted at least a minute placing more electrodes and obtaining said 12 lead.

If anything the reason I would apply the monitor to the second pt. would be to check for possible cause to the unresponsiveness, maybe a medical issue? The fact that he was unresponsive and now has a GCS of 15 doesn't really add up to me after a trauma event.

I may be a little laxed in treatments but I have always been aggressive with sick people and not so with stable patients. I don't practiced based on the fact of I do something because I can. I normally do interventions based off a need.... To each his own. No two medics will do everything the same. Thus why I love single ALS provider units

 

[Shishkabob]

Routine vitals huh, you must work in a very slow jurisdiction. So a nosebleed gets a 4 lead strip??

Preferably, yes, if the nosebleed was non-traumatic in nature. Could be caused by HTN, which could be caused by a dysrhythmia.



As for these scenarios? Why WOULDN'T you have an EKG on the bike rider who was initially unresponsive?



There's more than probably just you on scene. Slap the stickies on and take the automatic printout. Ta-da. Granted I have a 45+ min transport from the closest facility, so I get more time to toy around with my assessments...

 

[CANMAN]

IDK maybe its just me but I would tend to get a baseline set of vitals on a nosebleed/any call and go from there. If everything got cardiac monitoring then why don't we do away with BLS transport units, work everyone up, and bill ALS for everything. As an ALS provider you can link anything to a more serious condition if you think about it long enough. The fact that a nosebleed, could be caused by HTN, which could cause a cardiac issues is honestly not on my mind UNLESS the baseline vitals give me reason to think this way.

As said in my previous post, outta the two I would be more willing to workup the second dude based on the "unresponsiveness" but I am not going to delay transport to the hospital which is 5 MINS away to grab a 4 lead on a patient who now has a GCS of 15, normotensive VS, and regular pulse, just to confirm he is indeed in NSR??

 

[Mobey]

Routine vitals huh, you must work in a very slow jurisdiction. So a nosebleed gets a 4 lead strip??

Hmmm... I fail to see how adding a strip to a complete assessment correlates to call volume?
Perhaps it takes you alot longer than me (or my EMT partner) to put on a 4 lead.

Let's get real here, yes, every nosebleed. not every patient... but pretty well every patient.

Whats a 12 lead going to show you that is going to be something you can correct on scene?

I assess for all lifethreats/injuries. Not just the ones I can correct onscene.
Question for you; What CAN a 12 lead show us on a trauma pt? especially with chest injury?

I have to agree with TomB on this one. I don't see a need for either patient to be cardiac monitored. If both patients have normotensive vital signs to include pulse rate, and you palpate a regular pulse I think its VERY safe to say they are both in NSR.

Wow, rhythm identification from a radial pulse. Impressive.
I prefer a thorough assessment.

No offence TomB, you know I truly appreciate your knowledgebase and your effort to share that info when it comes to ECG's.

If anything the reason I would apply the monitor to the second pt. would be to check for possible cause to the unresponsiveness, maybe a medical issue? The fact that he was unresponsive and now has a GCS of 15 doesn't really add up to me after a trauma event.

THAT is the only reason?

I don't practiced based on the fact of I do something because I can. I normally do interventions based off a need....

Ahhh... there is why we see this so different.
You practice reactive medicine.
I practice proactive medicine.

 

[CANMAN]

Well I didn't mean to offend you, but like I said every Medic is different. I don't consider it Reactive vs. Proactive at all. I have yet to place myself in a "Reactive" situation on a call because of my lack to work someone up. Now have I worked someone up and had to react to changes sure, we all have, but never have I been lazy and had someone crump on me. I think call volume, experience, etc do have something to do with how aggressively I treat person. When I first came out of Paramedic school I wanted to work-up every single patient. Like I said before you CAN MAKE anything ALS and in a system where ALS resources are limited. I as a medic with plenty of experience both in and out of hospital have to make a medical decision on who really needs my services and what I should send BLS. If you are in a system that runs 20 calls a month its very easy to say sure we will work everyone up, but 20 calls a shift you have to know when to appropriately utilize ALS interventions.

I never said that I could identify the rhythm based off a radial pulse, what I said was with normal VS (HR 60-100) and a regular radial pulse I would feel pretty confident they are in NSR. Not 100% but it's most likely a good bet. This would also R/O Tachyarrhythmias which is something I would be initally concerned with. Utilizing a 12 lead I would be looking for conduction disturbances or a possible CA occlusion following the blunt chest trauma. Aside from that Angiography- Blunt Aortic Injury, Thoracic Ultrasound- Pericardial effusion, tamponade, hemothorax, etc all to be done BASED ON assessment findings at the hospital. If you think that everyone that c/o chest pain after a MVC gets or should get an Angiogram then I just don't agree.

I am just saying that every medic will treat various situations differently. While I may opted to not put a 20 y.o. male who c/o productive cough x 1 week and now has chest pain on the monitor you may, and god bless ya for it.

 

[medicdan]

Would you start a line on either of the patients? Are there any here that would BLS at least the first patient in to the hospital, aside from the cardiac monitoring? Do you consider that enough justification to bring the call to ALS1 billing? In some situations, that could be considered medicare fraud, no?

 

[medicdan]

also think about whether or if either of these patients are going to be on a cardiac monitor at the ED. Different hospitals take different perspectives on this...

 

[8jimi8]

I don't see how anyone is calling 2 pediatric mvcs bls.

Also, why is everyone got such a boner for the GCS?

What does that tell you besides awake moving extremities and following commands?

 

[rhan101277]

To clarify these are adult pedestrians.

Both are normotensive, IV's are started and TKO'd.

No major trauma on either individual but both require the paramedic to ride the call due to MOI.

Our system is 1 EMT, 1 Paramedic per unit. Some are 2 EMT but don't respond to 911.

 

[TomB]

Why WOULDN'T you have an EKG on the bike rider who was initially unresponsive?

Why wouldn't you apply bilateral traction splints?

 

[8jimi8]

Why wouldn't you apply bilateral traction splints?

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.