Couple simple questions

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atb123

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I'm a somewhat new medic in a fairly large urban department. I see there are lots of vetran medics here that I would like an opinion on regarding a few topics I have been thinkin' on.

1. Use of drugs in a pt. who codes on-scene/en route due to trauma


2. Use of 12 leads on pts. with pacemakers.

Appreciate the time. Thanks.
 
Here is my opinion;

1) In my experience patients in traumatic arrest will generally be in a PEA rhythm. While you can give EPI and Atropine if a brady PEA, it is important to fix underlying causes (H's & T's). Usually that means alot of fluids and Diesel therapy. The survival rate for traumatic arrest is pretty low.

2) I will still do a 12-lead on patients with pacemakers for several reasons.
a) Document a baseline that the pacemaker is working.
b) Some pacemakers work only when needed, so there is chance that you can acquire a non-paced 12-lead.
 
Traumatic arrest has very poor outcome. We even have a protocol for field termination on traumatic arrest. Alike decribed, the best is a PEA rythm. Identifying the factors, other than they are FUBAR, there is nothing anyone can do.

Unfortunately most Paramedics are poorly educated in pacers in general. Sequential pacing to atrial pacers, demand, confuse most of the medics. Twelve lead is just a better assessment tool and needs to be performed if there is a need to monitor a patient with primary cardiac problems or hx.

R/r 911
 
Thanks for the info.

I have been working with different partners pretty much every shift. So one day my senior partner will follow ACLS and do the epi/atropine on an aystole/PEA trauma and the next partner will not do any drugs on a trauma code. I feel you can defend either way, just interested in other's opinions.

Same with 12 lead on a pacemaker. One day partner wants to get a 12 lead on a paced and next shift Im putting 12 lead on a paced and another partner stops me and tells me it wont do any good.

I do talk to them about it, but being a pretty traditional fire dept. the whole I am the boss because Im senior thing is there.

Again, thanks for the info and looking forward to more.
 
If you are going to work a traumatic arrest, the one should follow fluid/blood resucitation and emergency agents just alike any cardiac arrest. Identifying possible indicators for such conditions for PEA.

No drugs in trauma/cardiac arrest is a definite outcome of being dead.

R/r 911
 
For any code that happens onscene or en route our company follows the "Which came first, the chicken or the egg" policy. We work the code because we have no way of knowing if a medical brought on the trauma or the other way around. We do 12 leads on pacemaker patients to see what we are working with and to get a baseline. In fact just had one this past Saturday.
 
On the traumatic arrest I also had the belief that the guy is pretty much dead no matter what. My preceptor had an award I asked him about one day that only two medics in the company have. He saved two trauma completes on the same wreck. I know this is the perfect sitution but dont lose hope and say to yourself this patient is dead no matter what I do. I dont want to wonder a week later if I did all I could for the patient. On the other hand Brains coming out in a trauma complete is a poor indicator. Just use your judgement.
On the 12 leads we are required to do one on Abdominal pains, Chest pains and SOB calls. But you still treat the chest pain no mater if there is stemi or not . So does the pacer masking the elevation really matter ? I guess since we get auditied if there is no 12 lead sent in on these calls it makes it easy for me . It doesnt take that long to do one and as Ridryer has said it is an easy differential tool
 
Just a quick question and not to distract from the primary questions of the thread... when treating a traumatic arrest, what are the opinions of performing a bilateral chest decompression? In Maryland, it is protocol to perform a bilateral chest decompression on ALL cardiac arrests of a traumatic etiology.

Do any other States have that in their protocols?
 
ResTech said:
Just a quick question and not to distract from the primary questions of the thread... when treating a traumatic arrest, what are the opinions of performing a bilateral chest decompression? In Maryland, it is protocol to perform a bilateral chest decompression on ALL cardiac arrests of a traumatic etiology.

Do any other States have that in their protocols?
Click to expand...

I understand the rationale but don't believe in the philosophy. Making blanket treatment of such is not really tx but rather having them do something.

Personally, when a patient of such traumatic means dies, sticking a 14g into each lung will probably do nothing. If the patient did not have a pnuemothorax, they do now.

The other argument will be, that it will not "hurt" as the patient has coded. In response, one could say performing an open cardiac massage would not either but we won't recommend that either.

There are very, very few circumstances that trauma patients are ever revived it would be much better for those type of arrests to be declared especially if arrested pre arrival per EMS.

R/r 911
 
Ridryder911 said:
If you are going to work a traumatic arrest, the one should follow fluid/blood resucitation and emergency agents just alike any cardiac arrest. Identifying possible indicators for such conditions for PEA.

No drugs in trauma/cardiac arrest is a definite outcome of being dead.

R/r 911
Click to expand...

To clarify...are you stating you recommend using ACLS drugs on a trauma in asystole or PEA? Besides the Hs, Ts, and fluid?

Thanks for the response.
 
atb123 said:
To clarify...are you stating you recommend using ACLS drugs on a trauma in asystole or PEA? Besides the Hs, Ts, and fluid?

Thanks for the response.
Click to expand...

You bet. An arrest is an arrest if you are going to resucitate them. One does not do half treatments. In addtion to medications, of course you attempt to identify the reason for PEA and of course fluid/blood resucitation.

R/r 911
 
Ridryder911 said:
Traumatic arrest has very poor outcome. We even have a protocol for field termination on traumatic arrest. Alike decribed, the best is a PEA rythm. Identifying the factors, other than they are FUBAR, there is nothing anyone can do.

Unfortunately most Paramedics are poorly educated in pacers in general. Sequential pacing to atrial pacers, demand, confuse most of the medics. Twelve lead is just a better assessment tool and needs to be performed if there is a need to monitor a patient with primary cardiac problems or hx.

R/r 911
Click to expand...


You are very correct on the lack of pacer info. We had a good amount of it in class, but how much can you really cram into a semester when you're covering all of CV including rhythms and 12 leads, plus med emerg and summative and clinicals all in the same semester? I remember looking at dozens and dozens of strips and having to pick out what type of pacer it was. Very cool stuff, but honestly, I have to think about it and stare at it before I'll spout off an answer.
 
atb123 said:
I'm a somewhat new medic in a fairly large urban department. I see there are lots of vetran medics here that I would like an opinion on regarding a few topics I have been thinkin' on.

1. Use of drugs in a pt. who codes on-scene/en route due to trauma


2. Use of 12 leads on pts. with pacemakers.

Appreciate the time. Thanks.
Click to expand...


1. Reread your ACLS protocols and get a good ACLS study guide type of book. The study guides tend to explain things in more detail than the regular ACLS book and are intended to be used along with the ACLS book. For a traumatic arrest, I agree with the others. Follow your algorithm for whatever rhythm has presented itself to you and think about the H's and T's. Traumatic arrests generally don't have good outcomes. Also remember ITLS and do a rapid trauma survey...is there anything you can fix? Bleeding? Pneumos? A/W obstruction? Are there injuries incompatible with life such as brain matter all over the place? Most services have protocols for terminating a code in the field in these situations. If in doubt, call med control.

2. As the others have said, 12 leads are an excellent diagnostic tool and should be used on your pts with pacemakers when needed. Just looking at more 12 leads will help you to read them and identify things better. Get a good EKG book and study. It can't hurt.
 
ResTech said:
Just a quick question and not to distract from the primary questions of the thread... when treating a traumatic arrest, what are the opinions of performing a bilateral chest decompression? In Maryland, it is protocol to perform a bilateral chest decompression on ALL cardiac arrests of a traumatic etiology.

Do any other States have that in their protocols?
Click to expand...

Our protocols say that we CAN do bilateral chest decompression on a traumatic arrest, but it's at the medic's discretion. I see this as a good thing and a bad thing. CD is always a standing order as a tension pneumo is life threatening, but you have to use your assessment skills to find it. In a traumatic arrest, you should still assess your pt and not just assume that they would need bilateral CD "just in case." I would rather treat it if it happens than create a pneumo "just in case."
 
bi-lateral decompressions in traum arrests

paccookie said:
Our protocols say that we CAN do bilateral chest decompression on a traumatic arrest, but it's at the medic's discretion. I see this as a good thing and a bad thing. CD is always a standing order as a tension pneumo is life threatening, but you have to use your assessment skills to find it. In a traumatic arrest, you should still assess your pt and not just assume that they would need bilateral CD "just in case." I would rather treat it if it happens than create a pneumo "just in case."
Click to expand...

As amtter of interest abig trauma study done here in Melbourne at the Alfred Hospital ( i mentioned it in a copule of other threads) determined that a number of trauma pts with non-sruvivable ISS scores actually survived because of prophylactic decompressions following assessment of PEA situations. It seems that these pts did have a tension but it is not always apparent.

I agree that thorough assessment needs to be performed but without a doubt a multi trauma pt partiularly with signs of chest injury should have his chest popped as a matter of urgency if in PEA. He may not be exsanguinating after all but rather shuttling off through tension pneumo induced tamponade. When you think about it a driver with a steering wheel related chest injury is a distinct possibilty in any high speed MVA for this to happen. Noting this in assessment of mechanism will often point in that direction.

MM
 
That is an interesting study finding... thanks for that bit of info.
 
Study

ResTech said:
That is an interesting study finding... thanks for that bit of info.
Click to expand...

I'll see if I can dig out a citation as the study was published in the literature.
Venty and Ryders are much better at referencing their remarks - I'll see if I can adopt similar excellent habits in the future.

cheers

MM
 
Melbourne MICA said:
As amtter of interest abig trauma study done here in Melbourne at the Alfred Hospital ( i mentioned it in a copule of other threads) determined that a number of trauma pts with non-sruvivable ISS scores actually survived because of prophylactic decompressions following assessment of PEA situations. It seems that these pts did have a tension but it is not always apparent.

I agree that thorough assessment needs to be performed but without a doubt a multi trauma pt partiularly with signs of chest injury should have his chest popped as a matter of urgency if in PEA. He may not be exsanguinating after all but rather shuttling off through tension pneumo induced tamponade. When you think about it a driver with a steering wheel related chest injury is a distinct possibilty in any high speed MVA for this to happen. Noting this in assessment of mechanism will often point in that direction.

MM
Click to expand...

There is quire of bit of difference in a non-survivable injury severity index score and those in traumatic arrest. I wonder what the differential is of those that was in traumatic arrest outcome that had decompression. If I see that to be worthy then yes.

R/r 911
 
Ridryder911 said:
There is quire of bit of difference in a non-survivable injury severity index score and those in traumatic arrest. I wonder what the differential is of those that was in traumatic arrest outcome that had decompression. If I see that to be worthy then yes.

R/r 911
Click to expand...

A fair point Ryders. I'll hunt around for the study. As a few of the guys said, most EMT-P's will look at traummatic arrests as an almost forgone conclusion as oppsosed to the pt who is just hanging in there. Most of the time their demise is from HI's or major vessl damage I would suggest. Still we can consider decompression in the setting of other cardiac arrests where you might get ROSC but inadequate perfusion. I guess you have to play all your cards if you're going to give the pt any sort of chance despite the sometimes obvious realities of the situation.

Thanks as always Ryders.

MM
 
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