please if anyone could help out

I

Intuit

Forum Ride Along
Messages
4
Reaction score
0
Points
1
Call for an unconscious. Took all of two minutes to get to the scene.

Facts:

Guy tumbles down a flight of metal train station stairs. He's lying supine on a landing between two flights, bleeding slowly from the head, unresponsive to pain- completely out, pupils non-reactive dilated, deep snoring respirations that LOOK VERY SIMILAR (heres where I'm having trouble) to agonal respirations regularly with good chest rise but too spread out to be effective. He's slowly going cyanotic. Thing is he has a strong regular slightly fast peripheral pulse.

The respirations looked so similar to agonal respirations that when another emt truck arrived and saw me and my mates applying a c-collar, OPA, setting up the O2 and BVM and readying the backboard they shouted at us for it "why are you wasting time on that" cause they thought he was in or was going to go into cardiac arrest.

We ended up getting their help immobilizing/ loading him onto a backboard, I ended up ventilating, cyanosis gone by the time we got him movin, medics arrived on scene at the bottom of the second flight of stairs. Got him into the truck, they hooked him up to lifepak and confirmed pulse was fine, blood pressure was normal, no signs of ICP, they hooked him up to an IV, game him god knows what and nothing woke him up. I patched his head up with a couple of 5'9s while they did their thing. About 5 minutes into transport medics reassessed his breathing and decided he didn't need to be ventilated anymore.

Got him to trauma center alive, he survived the trip, i don't know what ended up happening to him.

QUESTIONS

1)AHA guidelines for CPR says you're supposed to walk up to someone, and when you see that they are completely unresponsive check for a carotid pulse, and if you don't feel one or are not sure you start compressions. Had I done that and not felt a carotid pulse or thought I didn't, or immediately judged his respiratios to be agonal, I would have been performing compressions on a guy with a good pulse and ineffective respirations who just needed rapid transport and ventilation. What are your thoughts on this.

2)Is there any way to distinguish between agonal breaths and what I saw? Did I do anything wrong? Did I waste time with the c-collar? Why do I never see anyone use c-collars when they should?

3)what do you think was wrong with him? Why would he start breathing effectively on his own after several minutes being ventilated?

What could/should I have done differently?
 
Last edited by a moderator:
1.) you should be confident if you can feel a pulse or not. A patient with a pulse = no CPR but maybe rescue breathing. A patient without a pulse = CPR (unless obvious signs of death). Don't go by respiration rate or pattern to tell you if you need to do compressions. Always go by the pulses that you palpate.

2.) Agonal breaths are just gasps. They will not be deep at all. Snoring respirations = blocked airway. Also every time I have seen agonal respirations they are very slow, completely irregular, and shallow.

3.) Look in your EMT book or do a little research on blocked airways. Why does it happen? What is the most common airway obstruction? What does that cause the body to do? How can you, as an EMT fix it?
 
Last edited by a moderator:
What was his respiratory rate? Gag reflex? Where was he cyanotic? SPO2? How soon after ALS arrival did they stop bagging him? Did they go to NRB, cannula, room air? Did you adjust the airway, and did that correct the snoring resps?
 
Resp rate was 10. Cyanosis in the face. No gag reflex to the OPA. Adjusting the airway and inserting the OPA did not stop the snoring sound for some reason.

As for the 02 saturation I don't know because BLS here don't carry pulse oximeters but I head them saying "his 02 sat is improving" while I was bandaging his head. They had me switch him to NRB (to answer your question it was probably about 5 minutes into the ride)

I think the guy above you was right. But I'd appreciate your input
 
1. You certainly did the right thing by avoiding compressions in this situation. I'm afraid I don't understand the source of your confusion here. You felt a pulse, but judged his ventilations to be inadequate so assisted with a BVM. Good work!

2. Agonal respirations are, by definition, inadequate and not capable of moving any effective quantity of air. As mentioned above, they're irregular, spasmodic, shallow, and pretty obviously worthless. Head injuries can present with a variety of respiratory patterns with varying levels of effectiveness depending on what level of the brainstem is effected and to what degree. In most places, you're going to have to C-Collar this patient. Continuing evidence is showing that our definition of "spinal immobilization" doesn't really help patients, even if they do have a confirmed spinal cord injury. In this case, you did fine to rapidly apply a collar and board as required as you move on to more important interventions (IE, transport).

3. Presumably head and potentially spinal injuries. Really impossible to tell any kind of specifics from this type of scenario, but see if you can get some follow-up from the hospital for your own education. The patient's intrinsic respiratory effort could improve from positioning, increasing ventilations, or just a progression of the head bleed. Many respiratory patterns in traumatic brain injuries are irregular anyway. Also likely is that different providers assessing the patient led to different interpretations of what is effective versus ineffective effort. I'd be far more interested in clinical signs of respiratory adequacy than SpO2 in this case anyway.

FYI, I can't imagine anyone gave this patient anything other than saline in his IV pre-hospitally. There's no "God knows what" mystery medication that would "wake someone up" from a traumatic brain injury. The only medications I'd be administering would be sedatives and paralytics to RSI, and it doesn't sound like your ALS was able to go down that road. If this patient is as critical as it sounds, bright lights and cold steel are the only definitive treatment. I don't imagine ALS is carrying any kind of direct ICP monitor either, even if his vitals don't reflect textbook signs of increasing ICP.
 
Curious if anyone checked a blood sugar?

(And I bet they gave him Narcan, on the off chance he ingested opiates.)
 
Last edited by a moderator:
DEmedic said:
Curious if anyone checked a blood sugar?

(And I bet they gave him Narcan, on the off chance he ingested opiates.)
Click to expand...
I thought that's what he was implying, just didn't seem incredibly likely to me.
 
Last edited by a moderator:
At the very least a collar is indicated, and the backboard more to move the patient than to provide any sort of immobilization

In what situations are you seeing EMS not using the collar when you feel they should have been
 
I agree with DEmedic's point: Consider hypoglycemia as a possible cause of AMS, even when it looks like something else.
 
I was gonna say I bet he got narcan or D50. Saying they stopped ventilating him makes me think they were titrating it to a resp effort and that's why he never woke up.

Maybe I have too much faith in EMS providers though...
 
Come on Robby. You know thinking is hard.
 
You must log in or register to reply here.
Back
Top