Final school scenario

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Fraz

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Hey guys, I didn't really know where to post this so I decided to try here.

Protocols are based in Ontario Canada.

I had a final scenario last week in school, and the argument in class was that it could have went in two different directions. The scenario is as follows: (to as much as I can remember)

40 y/o male patient, stung by a wasp (known allergy) presents with late stages of anaphylaxis, edema around the mouth, wide spread urticaria (back, neck and arms), respirations noted at 36 rapid and weak, wheezes present in bases.

You have drawn up 0.3mg of Epinepherine as per protocol and your patient goes VSA. You administer the 0.3mg Epinepherine and note your patient doesn't have a pulse. You quickly start your defib protocol (see after). As you start your defib protol, fire notes they are having very little compliance with ventilations. Your monitor shows VF as your rhythm.

Which defib protocol do you see fit?
 
Linuss said:
The one that shocks Vfib.
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PCP's shock VF and Pulseless VT.

Choices are Foreign Body Airway Obs. or General Cardiac Arrest (Medical)
 
Witnessed Vfib arrest, defib it if you got paddles on him already. Get an airway. Or work towards shocking him while working on getting an airway (not shocking him while people are working on him). He needs both at this point.
 
General arrest. There is nothing to indicate anything in the airway, aside from possible laryngeal edema, and that's not considered a foreign body.
 
fma08 said:
Witnessed Vfib arrest, defib it if you got paddles on him already. Get an airway. Or work towards shocking him while working on getting an airway (not shocking him while people are working on him). He needs both at this point.
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It was witnessed, I put in an OPA and started my ventilations via. BVM. I got my partner to do CPR until I had monitor hooked up (circulate the epinepherine hopefully) and went from there.

Linuss said:
General arrest. There is nothing to indicate anything in the airway, aside from possible laryngeal edema, and that's not considered a foreign body.
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My teacher told me that it was Airway Obstruction and wouldn't fall under the General Arrest protocol.
 
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Well, without knowing your provinces protocols, or even your teachers rational, we can't go beyond that.


However... I'd venture to say shock him and treat the cause.
 
I'm with Linuss, general arrest is the protocol I would have gone with, laryngeal edema isn't a foreign body airway obstruction. He went into a witnessed vfib, immediately shock him if the pads are on anf continue down the algorithm. However it does make it more difficult without knowing the protocols in your providence.
 
Than answer here is surely pretty clear.

A foreign body protocol is going to be focused around removing/dislodging a foreign body. Right? What good is that going to do in airway oedema?

Do you have no flexibility at all to say, "I'm treating this person with a little from column A and a little from column B"? Does it really have to be one or the other?

If it does, without any familiarity with your protocols whatsoever, I can't say for sure, but I can't see the foreign body protocol being the right one.

In any case, the word protocol is being used too much in this conversation. I know you're a student and that you have to think a long the lines of which box this person fits into, but try to think about what the person needs, then figure out which of you protocols treat that need.
 
Here are the direct protocols from the Ontario ALS.

Foreign Body:
984i2s.jpg


General Arrest (Non-traumatic):
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30w038y.jpg


Basically, I used General Arrest (Non-traumatic) for my scenario and failed it because I was told I should have used the Foreign Body protocol.
 
Ask your teacher just how you're supposed to remove laryngeal edema with magill forceps....


Shock them ASAP, do CPR and get Epi on board quickly.

ACP wise you MIGHT have to consider a cric, if the trachea has already closed off. You want control of that airway, but that's not what caused the arrest.
 
If you had time to listen to lung sounds the prudent medic would have also looked in the mouth as well. If you saw a foreign object you would then try to remove it. As has been said good luck removing edema with magills or a finger sweep. It’s an arrest. Shock the vfib and run the arrest. Part of running the arrest is to treat reversible causes. Obtaining an airway is part of running an arrest. So in reality you are doing both.
 
Outbac1 said:
If you had time to listen to lung sounds the prudent medic would have also looked in the mouth as well. If you saw a foreign object you would then try to remove it. As has been said good luck removing edema with magills or a finger sweep. It’s an arrest. Shock the vfib and run the arrest. Part of running the arrest is to treat reversible causes. Obtaining an airway is part of running an arrest. So in reality you are doing both.
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Airway was clear. As I was drawing up my 0.3mg Epi the patient went VSA. I quickly gave my Epi as per protocol, started CPR to circulate it until defib could be hooked up and went from there. Once I put in my oral airway, I got no compliance on bagging, patient was still in VF so I treated this as a General Arrest Medical NOT Foreign Body.

I still don't understand how I was wrong? I wonder if I can contact my local Base Hospital to figure out what they would have done and then try and fight the exam.
 
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If it is as you state, and there was no hidden thing that he swallowed... you weren't wrong, your instructor is.



You don't treat an arrest from supposed anaphylaxis as an FBAO. Makes no sense, and I would call anyone out any day of the week that says otherwise.



DO what was stated before: Ask him just how you're supposed to fix laryngeal edema with magill forceps.
 
Linuss said:
If it is as you state, and there was no hidden thing that he swallowed... you weren't wrong, your instructor is.



You don't treat an arrest from supposed anaphylaxis as an FBAO. Makes no sense, and I would call anyone out any day of the week that says otherwise.



DO what was stated before: Ask him just how you're supposed to fix laryngeal edema with magill forceps.
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I did. PCP's can't use forceps anyways. The reply he gave me was "In your protocol, it states that after two minutes if you cannot secure an airway you have to treat it as a FBAO"

Adjusting didn't work (modified jaw thrust, head tilt chin lift etc), airways didn't work, nothing worked! How can I remove that? I did CPR concurrent with the defib guidelines (which was PERFECT by the way) and still failed it because apparently it's a FBAO.

:censored::censored::censored::censored:
 
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Adjusting didn't work (modified jaw thrust, head tilt chin lift etc), airways didn't work, nothing worked! How can I remove that?
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If you can't remove it go around it! Scalpal time!
 
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I suppose maybe the idea is that you are supposed to use the FBAO protocol because it seems to require more prompt transport. Which is what the guy needs if you don't have any cric qualified ALS.

Still, its a BS way of going about it.

Challenge it. Go armed with a good knowledge of the proper way of going about it and a perfect knowledge of guidelines.

I once had a disagreement with an examiner about adrenaline admin in anaphylaxis. The pt told me he was having an allergic reaction, had taken his epi pen, had stridor + obvious angioedema and was hypotensive and tachy. Essentially I walked in took a pressure while talking to him and then gave adrenaline. Got in trouble for not doing a full, by the book assessment. But i successfully challenged it on the basis of protecting his airway and that there was no piece of information that I would collect subsequently that would stop me from giving adrenaline. So give it a shot.
 
While the airway is not compromised by a FBAO, it is compromised. Going with the FBAO protocol, sans checking for obstructions to remove, seems like more of a PUHA situation according to your protocols. I think the thing to look at here is what is causing the Cardiac Arrest? In this situation, it's presumably a compromised airway so without fixing that you could shock him all day and not get a spontaneous return of circulation worth anything. I don't know if you can drop a combi-tube or any other airways in your area but it seems like if he would accept one it would be prudent. Obviously you want to hook him up and see i he is shockable but you need an airway ASAP. Just my 2 cents.
 
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