New EMT, don't understand a couple of calls.

[LucidResq]

Third-degree AVB is not v-fib or asystole. I'll have to look for the studies, but I believe the risks of a precordial thump are relatively low in a non pulse producing rhythm.

I know it isn't and I wasn't trying to use that study as evidence that precordial thumps are ineffective or harmful.... just thought it was interesting, since it's been mentioned on here that precordial thumps have caused commotio cordis, this was just an example.

I agree, the risks are generally low. I did dig this up though...

Our case highlights a previously undocumented complication following the use of a precordial thump: sternal fracture and osteomyelitis. This necessitated a modification to his coronary artery bypass graft surgery, and he required 6 weeks of intravenous antibiotics.

Ahmar, W., Morley, P., Marasco, S., Chan, W., and Aggarwal, A. 2007. Sternal fracture and osteomyelitis: An unusual complication of a precordial thump. Resuscitation 75:540-542.

Again, just a single case, but interesting (kinda crazy actually).

Other reported complications include deterioration of VT into VF, rate increase in VT, rib fractures, myocardial contusion, etc.... I guess it comes down to a risk-to-benefit thing which is complicated with these patients. Of course, chest compressions have the potential to cause similar types of physical damage... not sure about the effects on VT.

Sclarovsky, S., Kracoff, O. H., and Agmon, J. 1981. Acceleration of ventricular tachycardia induced by a chest thump. Chest 80:596-599.

Sclarovsky, S., Kracoff, O., Arditi, A., Strasberg, B., Zafrir, N., Lewin, R. F., and Agmon, J. 1982. Ventricular tachycardia "pleomorphism" induced by chest thump. Chest 81:97-98.

Befeler B. Mechanical stimulation of the heart. In Befeler B, editor. Selected topics in cardiac arrhythmias. New York: Futura Publishing Co, 1980; 185.

 

[Lifeguards For Life]

I know it isn't and I wasn't trying to use that study as evidence that precordial thumps are ineffective or harmful.... just thought it was interesting, since it's been mentioned on here that precordial thumps have caused commotio cordis, this was just an example.

I agree, the risks are generally low. I did dig this up though...



Ahmar, W., Morley, P., Marasco, S., Chan, W., and Aggarwal, A. 2007. Sternal fracture and osteomyelitis: An unusual complication of a precordial thump. Resuscitation 75:540-542.

Again, just a single case, but interesting (kinda crazy actually).

Other reported complications include deterioration of VT into VF, rate increase in VT, rib fractures, myocardial contusion, etc.... I guess it comes down to a risk-to-benefit thing which is complicated with these patients. Of course, chest compressions have the potential to cause similar types of physical damage... not sure about the effects on VT.

Sclarovsky, S., Kracoff, O. H., and Agmon, J. 1981. Acceleration of ventricular tachycardia induced by a chest thump. Chest 80:596-599.

Sclarovsky, S., Kracoff, O., Arditi, A., Strasberg, B., Zafrir, N., Lewin, R. F., and Agmon, J. 1982. Ventricular tachycardia "pleomorphism" induced by chest thump. Chest 81:97-98.

Befeler B. Mechanical stimulation of the heart. In Befeler B, editor. Selected topics in cardiac arrhythmias. New York: Futura Publishing Co, 1980; 185.

The AHA makes no recommendation for or against the use of the precordial thump by ACLS providers. However, the 2005 the International Liason Committee On Resuscitation guidelines indicate that one precoridal thump may be considered after a monitored cardiac arrest if a defibrillator is not immediately available.

The precordial thump should be considered within the first fifteen seconds of v-fib or pulse less v-tach (monitored arrests) if defibrillation is not immediately accessible [CLASS B; LOE IV]

In the case of witnessed arrest, out of hospital, after a baseball to the chest, after activating the emergency response system, I would still probably opt for the precordial thump.

 

[Melclin]

Cricket > Baseball

Cop a rick arm quick off a patchy wicket and you'll know all about it. Base ball is for sheilas

1.What is hyperglycemia? It is my thought that it simply means an excessive blood gluose level. The patient had a D-stick of 175, he said normal is around 120. He was laying on a bench at Wal-Mart, with an altered LOC, but signed a patient refusal because he was feeling better and didn't want to go with us.

Blood sugar can spike a little after corrections after a hypo. And it can then shoot back down. It's a little unclear what happened exactly, but I would be a little unhappy leaving him considering her was altered and you didn't have a BSL to definitely connect with his LOC, until he was very GCS 15, as long as he is a known diabetic and knows the score about post hypo big sandwich eating.

I thought anything above a 140, for anyone is considered hyperglycemic?

The lower limit is far more definite than the upper limit.

The AIC started asking her questions about WHY she did it, and started telling her that suicide was no way out

[/QUOTE]

Suggesting solutions or preaching at a person about suicide not being the answer is a poor choice in regards to someone who has just tried to kill themselves. It won't help and it may alienate them. It reflects the clinicians opinions on, and difficulty dealing with, the concept of suicide more than anything. I think as prehospital providers the most important thing is to do aside from showing the pt compassion (putting aside the fact that you yourself may be angry about the selfishness of suicide etc), is to collect information about the person's triggers, lifestyle, environment and support structure. It may be directly relevant to the pt's MSE and decision to discharge later down the track.

http://emedicine.medscape.com/article/288598-overview -- have a look at the risk factors section, and the suicide-typical MSE.

empathizing with the patient's pain helps them feel more trusting and understood, the physician can subtly begin inculcating hope with a positive attitude, a belief that the patient's circumstances and depression can improve and be treated successfully.

- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC419387/ -- I believe we do the first part of what that sentence mentions. We empathize. Correcting faulty logic is not appropriate at the point of crisis and it is something that a psychiatrist should be doing slowly over the next few days or weeks.

 

[Focallength]

Not to berate the OP, but how on earth can you be a EMT-B and not know what hyperglycemia is? Sorry but that is scary, are you in a non-NREMT state and they didnt go over this?

do you know what insulin shock/ diabetic coma is?

please dont take this the wrong way, I really am curious as to why you dont know what hyperglycemia is. It could be that Iam misreading your question too.

Also have you ever had a NC at 6lm in your nose? it feels like a blow dryer. Most patients would rip that thing out or complain that their nares are dry and bleeding in a few seconds. In my experience 9limited as it may be) different places have different protocols, NR may say place another bandage on top of the first, but your MD may rule otherwise.

 

[WashboardSlim]

So essentially what we have here is High Mortality and Low Frequency vs Low Mortality and High Frequency, right? Personally and purely from a statistical viewpoint, give me a serious thud to the chest - or, better yet, how about a better pitcher?

Also, there seems to be a torrent of fact-checking, case studies and references being thrown around in regard to commotio cordis and the precordial thump, and that's all well and good, but let's set up a scenario:

You've just been nailed in the sternum with a 149 gram baseball traveling at 90 mph - it has a kinetic energy of roughly 121 joules.

One of your team mates rushes to your side - turns out he's a bona fide medic student! He checks your ABC's and it looks like you're SOL - no pulse. It's going to be a little while before they grab the AED - say, 5 minutes. Now, your buddy knows how to do a precordial thump... And he looks awfully strong, so maybe he could whack you with 10 joules in the meantime. Would you want him to?

Now, before you answer, consider the Quantum Immortality thought experiment. Essentially, we'll be looking through the eyes of Schrodinger's cat for this one. For all intents and purposes, let's say with all the variables in play - the fact that we don't really know what rhythm you're in, nor the exact amount of energy needed to convert you, nor the amount one can provide at this exact moment - so let's call it 50-50.

Let's say he does it - if the many-worlds interpretation is correct, at this exact moment the universe will split to accommodate all possible outcomes, meaning you'll live and die several times over (which won't matter a whole lot, because as a conscious entity you'll cease to exist entirely, so we'll disregard these). Now, in the worlds that you HAVE survived, reality will continue to be observed and the chance of fatality will appear to have decreased. And for every precordial thump after the incident, it will appear to be less of a 50-50 shot (however, you will never reach a 0% chance of mortality).

So, essentially, the only way to decrease the chance of mortality is to let it ride and administer the precordial thump.

 

[VirginiaEMT]

Not to berate the OP, but how on earth can you be a EMT-B and not know what hyperglycemia is? Sorry but that is scary, are you in a non-NREMT state and they didnt go over this?

Of course I know what it is.. If you would read the original post, I was clarifying what I was told by an EMT-E. I wanted to make sure my understanding was correct.

do you know what insulin shock/ diabetic coma is?

Of course.. I hope you're not serious!!!!!!

please dont take this the wrong way, I really am curious as to why you dont know what hyperglycemia is. It could be that Iam misreading your question too.

You are, read again.. As you can see, from the post of far more experienced guys than you and me, that it varies for person to person, especially treatment and the diagnosis. I know what the book says, and I know what the state exam ask, and I know that it was one of my stations for my state practicals, which I passed with the 2nd best score out of 70 people testing, but the EMT-E had me second guessing what I thought, actually I know, I knew.

I am curious how you would define it?
Also have you ever had a NC at 6lm in your nose?

nope

it feels like a blow dryer. Most patients would rip that thing out or complain that their nares are dry and bleeding in a few seconds.

good point

In my experience 9limited as it may be) different places have different protocols, NR may say place another bandage on top of the first, but your MD may rule otherwise.

I guess he has....

He may have.

 

[VirginiaEMT]

This is a continuance from my last post. I am a vounteer that runs 1-2 nights a week, and I don't get to ask people questions every day of the week. I have been told by several EMT-E's and EMT-I's that I am one of the most competent BLS providers that they run with. I want to get really good at what I do, and advance in levels as time goes on.

So far, other than your post, this forum has been very generous with helping me and answering questions.

Please don't take this the wrong way, but I am usually seeking answers from people with a lot more knowledge than me, which means a Paramedic, EMT-E, EMT-I, etc. These are the people who can help me grow, and give me answers to the questions I may have because I want to know as much about the particular topic of my questions, and an EMT-B may not be able to provide that for me.

Keep on keepin on.

 

[usafmedic45]

Not to berate the OP, but how on earth can you be a EMT-B and not know what hyperglycemia is? Sorry but that is scary, are you in a non-NREMT state and they didnt go over this?

Even as the reigning "kick the newbie in the nuts" champ on EMTLife, I have to say that's a bit excessive. I've never seen it listed in a basic textbook where the problems begin with hyperglycemia. The symptoms? Yeah, but not the levels since in most states they (unless they were with a medic partner) never know the level in the field. I don't agree with it, but hey, I don't write the standards.

It could be that Iam misreading your question too.

You are. What he asked was:

I thought anything above a 140, for anyone is considered hyperglycemic?

Which is "technically" correct: 140 is the high end of normal fasting glucose range...granted it's not going to cause major problems but it's smart of the OP to ask about it. BTW, to the OP, yes, that's normal for someone's glucose to spike (slightly) after eating. It's why they tell you to fast before you are tested for diabetes.

complain that their nares are dry and bleeding in a few seconds.

14 years in EMS, 9 as an RT and I've never seen a nosebleed that fast from a nasal cannula. Not saying it is never going to happen, but I would not say that "most patients" experience it. The dry part, yes....any O2 through a cannula above two liters really should be humidified if at all possible.

In my experience 9limited as it may be) different places have different protocols, NR may say place another bandage on top of the first, but your MD may rule otherwise.

That is pretty much the standard practice. Never remove a dressing while bleeding is still ongoing. Personally I never remove it until at least 30 minutes after I've gotten the bleeding stopped or until I get to the hospital, whichever happens first. When working in EMS, it was always the latter.

 

[ajax]

I just want to add to the BSL discussion that if someone is feeling hypo at 200, they need resources to help them manage their diabetes better. Yes, some people are normally at 3-400s, but that isn't healthy, and getting a 3-400 BG patient to the ER is generally a good call.

I'd be more concerned about a pt with a 300 and ALOC than a pt with 50 and ALOC - the 50 can be easily treated at home (as long as the pt is conscious and hasn't had something unusual happen - like a pump malfunctioning and injecting 3 days of insulin in a matter of seconds) and the 300 is likely to progress to DKA. If the pt has an altered LOC with hyperglycemia (real high - 175 doesn't fit this bill), they're nearing DKA. DKA can cause cerebral edema, shock (from severe dehydration), and lots of other gross things, eventually leading to death - and the depletion of potassium in treating DKA (without an IV drip) can threaten cardiac rhythm.

I think that when we learn that lows are more dangerous than highs (immediately), we forget how dangerous highs can be (longer term, although especially for type 1 folks, not that much longer - DKA can happen in a matter of hours). However, a known diabetic without an ALOC and a BG of 300 wouldn't really concern me, except i'd wonder what inspired them to call...

Also, after hypoglycemia, BG spiking is normal, and LOC trails that - so people will sometimes still "feel" 50 twenty minutes after the 50, when their BG is now 175. The note about dropping again is important, too. Rapid spikes lead to rapid drops, so watch your patient eat something with protein, fat, and carbs before you let them sign out AMA.

 

[MrBrown]

This is my point, wouldn't this be a reason for the high flowo2. It would have been my guess that because of the blood loss, we should have given high flow o2 to prevent her from becoming shocky instead of waiting for her to get shocky.

Hmmm ..... more on this later.

I need sleep before I die, good day now.

*Brown takes off his orange jumpsuit and gets into bed.

 

[usafmedic45]

we should have given high flow o2 to prevent her from becoming shocky instead of waiting for her to get shocky

Seriously....I don't have polite words to describe how....never mind....I'm not getting banned over this.

Go review what causes hypovolemic shock instead of buying more equipment. It's better to stock your brain with information than your car with gear you may not know when (or more importantly, when not to use it) and how to use.

 

[MrBrown]

I'm not getting banned over this.

Seriously!

 

[VirginiaEMT]

Seriously....I don't have polite words to describe how....never mind....I'm not getting banned over this.

Go review what causes hypovolemic shock instead of buying more equipment. It's better to stock your brain with information than your car with gear you may not know when (or more importantly, when not to use it) and how to use.

Yeah whatever. I guess I need to get te 80's out of my mind, where I ran as an EMT for 7 years, and get into 21st century thinking. You may have been in diapers back then, but we would absolutely woul not give a COPD patient more than 2lpm O2 via NC, regardless, not exceptions. We had hyperventilating patients breathing into paper bags. I need to get that old crap out of my head and start doing things the way they are done today.

By the way, if you have something to add, feel free, I'm a really big boy.
If I value your opinion, I may be offended, if not, well you get the point.

 

[VirginiaEMT]

opps, double post

 

[VirginiaEMT]

Seriously....I don't have polite words to describe how....never mind....I'm not getting banned over this.

Go review what causes hypovolemic shock instead of buying more equipment. It's better to stock your brain with information than your car with gear you may not know when (or more importantly, when not to use it) and how to use.

EXPLANATION


My textbook BRADY Emergency care 11th Edition

Chapter: Bleeding and Shock page 621

Of course direct pressure,elevation,pressure point, and last resort torniquet

BUT it also states word for word under PATIENT CARE

In addition to controlling bleeding, an important treatment for ANY TRAUMA PATIENT is "administration of oxygen"
Blood loss decreases perfusion. This means that LESS oxygen is delivered to the tissues. The administration of supplemental oxygen will increase the oxygen saturation of the blood that is still in the patients circulatory system, improving oxygenation of the tissues.

Everything I studied about oxygen stated 15 LPM via NRB is the answer. The state Exam, the practicals, the class exam, the class final exam...........

It would be a great help if you would simply say " You may have misunderstood blah,blah,blah, but this is a correct way of doing blah,blah,blah, or maybe you could suggest reading material, or online training, etc.

I would really appreciate your help..

 

[JPINFV]

Oxygen administration will not stop shock due to blood loss. Similarly, it will not decrease hypoxia in a patient with a saturation near 100% since the differenece in dissolved concentration goes from extremely tiny to very very tiny.

CaO2 = (SaO2 x Hb x 1.34) + .003(PaO2)

 

[Ridryder911]

Yeah whatever. I guess I need to get te 80's out of my mind, where I ran as an EMT for 7 years, and get into 21st century thinking. You may have been in diapers back then, but we would absolutely woul not give a COPD patient more than 2lpm O2 via NC, regardless, not exceptions. We had hyperventilating patients breathing into paper bags. I need to get that old crap out of my head and start doing things the way they are done today.

By the way, if you have something to add, feel free, I'm a really big boy.
If I value your opinion, I may be offended, if not, well you get the point.

I was an Paramedic in 70's and 80's and sorry I even knew better than that back then.. I was taught "oxygen toxicity" was a myth. One of the ONLY reasons was not that you would shut down respiratory drive BUT you could not handle and control airway and respiratory depression. Hence... was told to withhold than to really know what to do. The same crap nurses was taught until they figured out critical and emergency nurses can be taught be and be educated in airway management.

Please; also quoting from an EMS textbook is embarrassing as most are only written at elementary or mid-level. So scientific and true medical information needs to have other resources and references.

R/r 911

 

[EMTinNEPA]

Oxygen will not fix hypovolemic shock. The problem is not a lack of oxygen, it is a lack of circulating blood with hemoglobin to deliver oxygen to the cells of the body due to hemorrhaging.

Yes, oxygen can kill the hypoxic drive of a COPDer, but not during the 20 minute ride to the hospital. You NEVER withhold oxygen from somebody who needs it.

As for the emotional coaching of the suicidal patient, we're here to treat patients... sometimes their problems are more psychological than anything. Also, her pupils may be dilated, but I'm willing to bet that's mostly sympathetic tone. If her color is good and she's hemodynamically stable, then why treat for shock? I understand if she's tachycardic that may be a little concerning, but if the blood loss wasn't that significant, I wouldn't worry... again probably more sympathetic tone than anything else.

As for commotio cordis, it's been pretty well covered. The only thing I can add is that it can only occur during a very short window in ventricular repolarization called the "relative refractory period".

 

[VirginiaEMT]

I was an Paramedic in 70's and 80's and sorry I even knew better than that back then.. I was taught "oxygen toxicity" was a myth. One of the ONLY reasons was not that you would shut down respiratory drive BUT you could not handle and control airway and respiratory depression. Hence... was told to withhold than to really know what to do. The same crap nurses was taught until they figured out critical and emergency nurses can be taught be and be educated in airway management.

Please; also quoting from an EMS textbook is embarrassing as most are only written at elementary or mid-level. So scientific and true medical information needs to have other resources and references.

R/r 911

Big difference in a Paramedic and an EMT-A, heck we did not even have Paramedics in this area, heck we didn't even man the station, in the 80's.We still don't have very many Paramedics. I believe the highest level in this area in the 80's was a shock trauma tech. It's been a while. I think the only paramedic I saw was on Emergency.

I quoted out of the book to explain my confusion not to prove I was right. I only used it to show what I was taught and where the confusion is coming from.

 

[VirginiaEMT]

Oxygen will not fix hypovolemic shock. The problem is not a lack of oxygen, it is a lack of circulating blood with hemoglobin to deliver oxygen to the cells of the body due to hemorrhaging.

Yes, oxygen can kill the hypoxic drive of a COPDer, but not during the 20 minute ride to the hospital. You NEVER withhold oxygen from somebody who needs it.

As for the emotional coaching of the suicidal patient, we're here to treat patients... sometimes their problems are more psychological than anything. Also, her pupils may be dilated, but I'm willing to bet that's mostly sympathetic tone. If her color is good and she's hemodynamically stable, then why treat for shock? I understand if she's tachycardic that may be a little concerning, but if the blood loss wasn't that significant, I wouldn't worry... again probably more sympathetic tone than anything else.

As for commotio cordis, it's been pretty well covered. The only thing I can add is that it can only occur during a very short window in ventricular repolarization called the "relative refractory period".

Thank you for your help.