Lets try some scenarios..shall we

TKO

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I follow my provincial rules (PCT) and Canadian Heart & Stroke guidelines. I like CH&S better than the AHA, as it makes more sense. Which is odd because the new CPR really was born out of Seattle (Good job, WA EMS!!).

We don't typically thump an unwitnessed, but things have really changed recently for us. We have a con-ed course that is all about new approaches to treatment guidelines. Things like, PCT for unwitnessed pts if you are only a few minutes getting to the party because it won't hurt the pt and you still have a good chance it's going to be helpful at this point. We also can shock children if nothing else is working. Protocols say we only shock kids if they have a cardiac hx, victim of blunt trauma to the chest or electrical injury....but now we can shock if we've done everything else.

This new Think Outside the Box approach is great for us. No more, "Well, it's outside the protocol so I can't" or just not close enough - here's your cigar. Like, pt is hypoglycemic but not diabetic? Give a tube of glucogel anyway.

D'uh! Finally a real first aid approach to BLS.


OK, here is a scenario: 63 y/o m pt c/o chest pain x 3 hrs and worsening. Pt doesn't really know their hx too well, but has 4 y/o NTG sprayer in with their meds, and it is in their name but they don't have a current script for it.

Your partner started O2 via NRB@15 Lpm and tells you B/P = 160/100, pulse=90, RR=24 (SPO2@RA=89%).

What do you do with this?
 

TKO

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OH, I have another one for people who want to try other. I think this is a good one because I really don't think many rescuers are adequately trained when dealing with burns. I'm really eager to hear Rid weigh in on this one.

You are called to a fire. Pt brought to you by FD found inside, UnCx. RBS reveals 3rd degree burns to most of L arm and L chest. No other injuries. lungs are AE=AE x4.

Go!
 

lcbjr3000

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For the first one with the 63 yo with chest pain, Have him rate the pain, ask what he was doing when the pain started. I forgot to call for ALS backup since it is more than likely a cardiac problem. Check if pain has improved after O2 therapy. Reasses vitals and check lung sounds. As for the nitro spray, im not too familiar with the shelf of nitro but im pretty sure 4 years is too long. If you carry nitro you can contact med control and advise them on pts condition and more than likely you will be told to give nitro. Moniter vitals and transport. Hopefully and als intercept along the way.
 
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Ridryder911

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OH, I have another one for people who want to try other. I think this is a good one because I really don't think many rescuers are adequately trained when dealing with burns. I'm really eager to hear Rid weigh in on this one.

You are called to a fire. Pt brought to you by FD found inside, UnCx. RBS reveals 3rd degree burns to most of L arm and L chest. No other injuries. lungs are AE=AE x4.

Go!

I'll await for others to answer and reply before answering... ;)
 

lcbjr3000

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2nd scenario. First of all with unconscious you have to protect the airway. Insert OPA/NPA assist ventilations with bvm connected to high flow O2 at rate of 12-20/min. cover the wounds with dry sterlie dressing. Get vitals. If you have the ability to, start an IV preferably Lactated Ringers, but saline will do. transport to hospital. Im not sure what you meant by lungs are AE=AE x4 probably something simple but im not familiar with the abbreviation
 
OP
piranah

piranah

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well is the burn PT breathing?1.dress the wounds and get ALS to start some fluid lines.2. put on O2 via NRB at 15 lpm ,3.transport ,I would be concerned with possible inhalation burns....not enouph info in that segment..
 

TKO

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Any of you need to cool the burns for 10 minutes? Burns are extremely painful and cooling is the best thing for that pain. Hypothermia and infection are serious issues. But I digress as I believe that Rid will give us a better rundown of how to handle burn pts and why (and I'm rather eager as I consider myself inadequately prepared for serious burns, as most other rescuers are since few can ever give me straight answers).



Chest pain scenario: in your focused, palpate around sternum and ask if it hurts? No? Not muscular. Ask pt to take a deep breath? No? Not pleuritic (especially check if SOB ). Pt *had* a script for NTG, that is now expired; you should call your ED and get orders for the nitro since pt previously had a script. Everything else looks good, just ask the pt why they don't still take nitro.
Now if ED says No, give ASA and transport.
 
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paccookie

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2nd scenario. First of all with unconscious you have to protect the airway. Insert OPA/NPA assist ventilations with bvm connected to high flow O2 at rate of 12-20/min. cover the wounds with dry sterlie dressing. Get vitals. If you have the ability to, start an IV preferably Lactated Ringers, but saline will do. transport to hospital. Im not sure what you meant by lungs are AE=AE x4 probably something simple but im not familiar with the abbreviation

Agree with the above, except for a couple of things.

Call for ALS back up immediately due to unconscious patient who likely will need an advanced airway, among other ALS skills. Cover the wounds with a cool, wet dressing - sterile 4x4s wet with sterile water would work. Definitely start an IV, 2 if you can. I think I remember reading that 1 bag NS and 1 bag LR is a good idea. Estimate the area of the burn and start the Parkland (?) formula for fluid resusitation. Call medical control for any further orders and transport emergency to the nearest APPROPRIATE facility.

I don't have much experience with burns, so I will be interested to read the other responses as well.
 
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Outbac1

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On the c/p call, investigate the type and location of pain more and hx while getting vitals. Rule out pleurtic and muscular, rule in cardiac if this is where hx and dx takes you, for now I'll assume cardiac. O2 via n/c at 4lpm, 4 lead ecg, set monitor to diagnostic (instead of monitor mode, we use a lifepac 12) and set leads to 11, 111, AVF. This gives a quick rt sided picture while you set up for a 12 lead. ASA if no allergy. IV if allowed,(lock or tko). Nitro sl 0.4mg if bp >90s, (personaly I prefer a pressure greater than 110s). Transport to hosp. Depending on pain and relief with nitro, (I can give 0.4mg sl x3), info from ecgs, patient stability and transport time call ALS as required. If the pt. is pain free now and has no other priorty symptoms we transport w/o ALS.
 

certguy

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2nd car crash scenerio

Just because you don't have your rig with all it's fancy gear doesn't mean there's nothing you can do for the women in the trans am . You guys are spoiled rotten . Though by mechanism , the bonehead that hit them should go to the trauma center , for now , he's a delayed pt. . Your priorities are the red tags . You have O2 , c - collars , basic gear , and the means to take baseline vitals . Though you can't open the doors or fully access the pts. , you do have limited access through the windows . You can have PD get the helo in the air and save some time there also . As with most MVA's there are probably some spontaneous volunteers willing to help . Put them to work stabilizing c - spine , writing down pt. info , and post a lookout with a fire extinguisher for safety , and babysitting the other driver , to free you up to do what you can . In the initial post , I said traffic's at a complete stop , and you're in uniform on the way to work . You're not getting there any time soon and you can't get off the freeway . You have lifesaving skills and the basic gear to get things rolling till first responders get there . It's flat wrong for EMS people to let people die in this type of situation without lifting a finger because of fear of a lawsuit . It amazes me there's this much fear going around that it would cloud your judgement .
 

Outbac1

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The burn pt needs ALS enroute ASAP. The u/c pt needs a definative airway and fluid mgt. Start with a NPA/OPA and bag with 100% O2, Prepare pt for transport and get moving. Remove clothing, except what is stuck and cover with sterile sheets. Vitals now if not already gotten. I assume lung sounds are equal and clear x 4 fields. Doesn't mean they will stay this way, monitor for changes often. Radio hosp early so they can prepare, smaller hosps don't get that many burn pts. I would quick estimate burn as 18 - 20%, Arm 9%, Ant. L side chest 9%, round off to 20%. If L side posterior chest included add another 9%, total 27%. Parkland would indicate 20% x 4ml = 80ml x kg of pt. If pt 80kg(176lb) would equal 6400 ml in first 24hrs. 50% in first 8 hrs. 3200ml / 8 = 400ml/hr = 400gtt/min with 60gtt set or 70gtt/min with 10gtt set, (just over 1 gtt/sec). That should keep you busy until ALS arrives or you get to hosp.
 
OP
piranah

piranah

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well....there is a thing called the "good sumaritan act" its a law protecting off-duty health care workers or just anyone who helps at emergency scenes.im not sure if this is just RI though.it was basically an incentive for regular people to help at scenes without the fear of a lawsuit.....i myself help at any scene i can and im legally obligated as a EMS worker in RI to stop at any scene that no help has arrived yet....not that anyone would ever know if i drove by but i still feel like its my job.....and i like doing it anyway...
 

Ridryder911

EMS Guru
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I realize burns are pretty scary. I had worked in the field for about twelve years before working as a burn nurse at one of the largest burn centers in the world. We had 10 ICU burn beds and about 20 burn beds, and two HBO units. I truthfully can say I learned a lot about different emergencies.

Ironically, I learned that NO one usually dies from burns themselves, but that they died from burn complications. I was amazed at the different levels of and types of shock syndromes I have witnessed. I only thought I knew shock physiology. As well, I witnessed a whole different way of resuscitation in a cardiac arrest of 31 year old. Very little to no cardiac medications were administered, and a successful result was from infusing and administrations of electrolytes, again treating the cause not just the effect. Again, a real eye opener.

Here is a very good web site with the American Burn Association (ABA)guidelines from the Advanced Burn Life support Course (ABLS).

http://www.saems.net/Downloads/50152_Burn Center2col_f.pdf

I highly suggest looking through it and then attempt to treat the scenario accordingly..I will review and clarify if needed.

Good luck,

R/r 911
 

Ridryder911

EMS Guru
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well....there is a thing called the "good sumaritan act" its a law protecting off-duty health care workers or just anyone who helps at emergency scenes.im not sure if this is just RI though.it was basically an incentive for regular people to help at scenes without the fear of a lawsuit.....i myself help at any scene i can and im legally obligated as a EMS worker in RI to stop at any scene that no help has arrived yet....not that anyone would ever know if i drove by but i still feel like its my job.....and i like doing it anyway...


Actually, it is called the Good Samaritan Act (from the Bible). Which was enacted from an article in the Reader's Digest during the early 50's. It was described that physicians were not stopping at MVA's off duty and people were dying. Ironically, there had not been any medical negligence law suits until after that article had been published (good idea?).

It does cover those that do not have a duty to act (was summoned) but usually not those that are associated with volunteers and professional services. Although, technically anyone can sue for anything. Then again, as long one acts accordingly to the level for off duty (first responder level); no matter what level or license; except medical physicians.

There are different interpretations of the law, but the general consensus is the same idea.

R/r 911
 

DesertRatetteEMT

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Call/have someone call 911
position airway
expose chest
check for pulses
begin compressions

u/a of buddy with some gear......

stop compressions and check abc's
have buddy take over compressions/verify they are adequate.
Place and OPA/NPA(prob not unless on duty, I'm not sure about the legalities of using an airway adjunct off duty) and ventilate at 30/2 until ems arrives
continue CPR.
This is extremely helpful to me as a student. They are really not too generous on providing scenario solving exercises in class at my school, and it is quite frustrating. Having a team of people here asking and answering more questions than the one-a-chapter in the book is refreshing and thought provoking. Keep it going! It's great!
 

enjoynz

Lady Enjoynz
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Just with regards to the burns scenario.
(And I will check out the site you have suggested looking at Rid).

Our protocol for the treatment of burns pt's has changed recently.
We have to cool the burns for 20 minutes now, instead of 10 mins.
And we cover the burns with Cling film (Glad wrap) to protect loss of fluids, infection control and also for the fact that you can still see the burns through the film.

I know in the case of this scenario the pt is unconscious, so you wouldn't be hanging around to long on scene.
But I'd be interested to know if any other services use cling film for burns pt's and their cooling times?

Cheers Enjoynz
 
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BossyCow

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Here's one from my archives.

Toned out to man found unresponsive in vehicle outside laundromat at 03:00. Arrive to find male, late 60's, sitting on ground next to vehicle. He is only alert to verbal and the only info we can get out of him is his first name. Diaphoretic, flushed, no visible sign of trauma. Pulse rapid, thready/ BP was 108/palp.
 

TheAfterAffect

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Here's one from my archives.

Toned out to man found unresponsive in vehicle outside laundromat at 03:00. Arrive to find male, late 60's, sitting on ground next to vehicle. He is only alert to verbal and the only info we can get out of him is his first name. Diaphoretic, flushed, no visible sign of trauma. Pulse rapid, thready/ BP was 108/palp.

Load em onto a stretcher, Fowlers Position (since he was found sitting and apparently thats his position of comfort), 15 LPM O2 Via NRB, request ALS Support to meet up during transport if possible. Transport to nearest hospital, and check Vitals every 2 minutes along the way.
 

lcbjr3000

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Assess respirations and start some O2 10-15nrb. Get your glucometer and get a blood sugar reading. If the person is responsive enough get a history and find out what happened so early this morning. Check lung sounds as well. Also it would be a good idea to run him through the cinncinatti stroke scale. Alert ALS possibly for the need of naxalone. Also the als will be able to set up cardiac moniter and see if this is a cardiac event. If diabetic they will need D50. I wouldnt try oral sugar because he could go unresponsive again then your just making things worse. Thats all i got for now im sure i missed something.
 

paccookie

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Here's one from my archives.

Toned out to man found unresponsive in vehicle outside laundromat at 03:00. Arrive to find male, late 60's, sitting on ground next to vehicle. He is only alert to verbal and the only info we can get out of him is his first name. Diaphoretic, flushed, no visible sign of trauma. Pulse rapid, thready/ BP was 108/palp.

If not ALS unit, call for ALS back up immediately due to LOC. Check blood glucose immediately. Administer O2 15L NRB. Cardiac monitor. If blood glucose is low, start an IV, hang normal saline at wide open rate, and administer thiamine & D50 or glucagon if unable to obtain IV. If IV obtained, KVO normal saline used to administer D50. Recheck vitals and blood glucose en route to hospital. Assess for stroke and drug use, obtain history as patient becomes more responsive.
 
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