That extra 60 seconds.

[VentMedic]

I was making a point. I TEACH ACLS as an EP instructor, and have for quite a few years. I understand and use doppler. I also stand by my statements. Go play with your toys, I will continue to save actual patients.

I repeat my original question:

What would a doppler have done to help this patient? Nothing. This was a cardiogenic event. Doppler will solve nothing here.

I am out of this pointless conversation.

This conversation started with my reply to this post:

...NOW! for those of you who are calling BS on this, then you obviousley have never witnessed this... fair enough. IT HAPPENED!! haha, didnt think it was possible myself! He was pulseless and completely asymptomatic (0/10 CP) but still awake and talking to us... crazy thing to see.

As an ACLS, maybe you should get the new book and update your literature sources to at least 2005.

 

[mycrofft]

So, how long does Uncle Morty last...

...from this condition's inception before he first starts shedding brain and kidney cells, then winds up with his liver temperature being taken?
What can be done by laypersons on scene if these conditons ensue?
How long will one spend figuring what to definitvely do versus the first question?

I am appalled by the price of medical devices and their persnickety construction. If NASA can contract and get machines that withstand rocket launchings, zero gravity, Van Allen belt radiation, banging down on Mars in an airbag then rove the surface years longer than planned, I do not understand why they can't come out with an ultrasound (or any other device) with similar characteristics and a low price after amortization and before malpractice insurance.

 

[boingo]

B]

One way I look at it is like this:

If the Pt is pulseless, consider that it takes a systolic BP of 40 to produce a palpable carotid pulse. With that fact in mind, a patient that has no palpable carotid pulse cannot be perfusing the brain with the required oxygen. Doppler is a waste of time. The goal here is to deliver O2 to the brain, and while a systolic of 30 may be detectable with a doppler, who cares? The brain is still starving for oxygen.

If he's awake, he's perfusing his brain, maybe not adequately, but perfusing none the less.

A cardiac patient who is having an inferior MI will frequently present atypically- they will most often complain of nausea and vertigo. Such a patient who has a seizure is likely experiencing runs of VT or VF. In such a case, time is critical and preventing the patient from going over the edge is a challenge.

The seizure activity is most likely the pseudo-seizure activity seen with syncope. A patient with a heart rate of 30 would likely have a syncopal event.

You did not mention what rhythm was producing the HR of 30. Was this a wide complex brady? Possibly a ventricular escape rhythm? Or was it a high degree AV block? Since this was an inferior wall, did you perform a 12 lead containing a right sided lead, such as V4R? If there was right sided involvement, that further complicates things.

Should have been done.

Atropine given in such cases has been known to precipitate VF. Atropine increases myocardial oxygen demand, and if it fails to increase cardiac output in the process, you have just made the problem worse.

Atropine increases myocardial oxygen demand by increasing heart rate. The faster a heart beats, the more o2 it consumes. If the atropine fails to increase hr, it shouldn't increase MVO2. Depending on underlying rythm, atropine could prove useful.

A better choice in such a case could be dopamine at 2-10 mcg/kg/min, assuming that pacing is not possible. Remember that this is a cardiogenic shock you are dealing with here.

TCP may be better than adding another drug to the mix. Dopamine may end up being used, but a rate of 30 needs to be addressed, and TCP would be the way to do it.

 

[traumateam1]

Sorry, a bit of a sidetrack...

Really? We were taught 60 mmHg for perfusion of the brain (palpable carotid pulse). 70 mmHg for femoral, and 80mmHg for radial. Is this not right?

Yeah thats what I was taught too.. well a little different.

60 mmHg for Carotid.
70-80 mmHg for Femoral
and 90 mmHg for Radial

 

[JPINFV]

This is a small study with some glaring short comings, but it does give something to talk about.

"Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study"

After obtaining approval of the study by the ethics committee, we studied sequential patients with hypotension secondary to hypovolaemic shock and in whom invasive arterial blood pressure monitoring had been established. An observer blinded to the blood pressure palpated the radial, femoral, and carotid pulses, and the invasive systolic blood pressure was recorded.

The advanced trauma life support guidelines for assessing systolic blood pressure are inaccurate and generally overestimate the patient's systolic blood pressure and therefore underestimate the degree of hypovolaemia. The minimum blood pressure predicted by the guidelines was exceeded in only four of 20 patients. The mean blood pressure and reference range obtained for each group indicate that the guidelines overestimate the systolic blood pressure associated with the number of pulses present. This study therefore does not support the teaching of the advanced trauma life support course on the relation between palpable pulses and systolic blood pressure.

-Deakin, C. D., Low, J. L. "Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using carotid, femoral, and radial pulses: observational study." BMJ 2000;321:673-674

http://www.bmj.com/cgi/content/full/321/7262/673

 

[ChristinaM]

We have the same type dispatch system here... called EMD certified dispatching... just coming online to us. Our dispatchers also leave it up to us as to how we respond - responding (lights and sirens) or en route (no lights and sirens). They will even say "your discretion" when asked. All of us have gotten burned one way or the other. Dispatching is a job I would never want to have and they go on what information they have.

Recently we were dispatched to a "fall" at a local ALF only to arrive and find that the patient fell down dead... just so happens he was coming down a flight of concrete steps at the time he had a significant cardiac event, stroke, etc., and smacked the back of his head to boot. We were informed that CPR was in progress as we casually strolled up to the patient's location. Thankfully, we have everything we need to work a code, except suction, right on our stretcher.

You can only do what you can do and no more. No need to beat yourself up. Though there are those out there that may think so... we are not Gods.

 

[daedalus]

??????????????

If that was the treatment, you probably did not do the patient any favors by getting to the scene. Although that could be a matter of opinion since prolonging the inevitable is difficult also.

Look up the probability of survival for an MI that massive. Once you understand a little more about medicine, you realize what your capabilities are and what those of nature or a higher God than EMT(P) are.

I agree!!!

The 60 seconds would not have saved the pt, but the ADENOSINE you gave killed him! Look up the studies on adenosine for MI! What were you thinking!!??

 

[daedalus]

The call information just sounds sketchy at best. Like others have been saying, you treat the patient and not the monitor, but I find it hard to believe that a patient who has no palpable pulse or blood pressure, and who is suffering from a STEMI that later killed him is going to be completely asymptomatic. I have personally seen an asymptomatic STEMI patient who's ST segments were taller than the R waves, but she had so much morphine and metoprolol in her that it really didn't surprise me. With no drugs on board, no pulse and no BP this pt isn't going to be "awake and talking with 0/10 CP", and if they are alive, they won't be for long. That is just intuitive. All of that, coupled with the report of adenosine administered, just makes this story very sketchy. Either the OP was exaggerating, or someone who told him the story was mistaken, which isn't too far fetched. Stories are easily skewed as they're told from person to person.

I just got back from an emergency CCT call. We picked up a pt from a rinky dink ER and brought him to County USC med center. He had massive elevation on the monitor and no pain. His only complaint was anxiety and not feeling right.

 

[YYCmedic]

I agree!!!

The 60 seconds would not have saved the pt, but the ADENOSINE you gave killed him! Look up the studies on adenosine for MI! What were you thinking!!??

I already fixed my post about the Adenosine, haha I'm really not retarded just a symple typo at 3am during a loooong shift hahaha.

 

[ErinCooley]

This is yet another area where I really show the newbie...

are there seriously areas where dispatch decides whether lights and sirens are warranted? Is that not a HUGE liability???

In my county, if you call 911, youre getting a truck w/ lights and sirens, even if you request no l/s due to liablity.

 

[reaper]

Yes, it is called EMD (Emergency Medical Dispatch) Almost every large city uses it now. It was designed to cut down on the amount of calls ran L/S. Not every call needs a L/S response and it puts your crews in unnecessary danger.

If a caller calls 911 and states that they were jogging and twisted their ankle, would you want to run L/S to this call?

 

[rescuepoppy]

Yes, it is called EMD (Emergency Medical Dispatch) Almost every large city uses it now. It was designed to cut down on the amount of calls ran L/S. Not every call needs a L/S response and it puts your crews in unnecessary danger.

If a caller calls 911 and states that they were jogging and twisted their ankle, would you want to run L/S to this call?

Just to keep in line with the post those extra sixty seconds probably would not have mattered. To address the matter of dispatch areas that use the EMD systems also use EMDPRS cards that are guidlines as to how to dispatch the call. These are set up to help reduce the unneeded lights and siren response to every call and when properly used can be a tool to help reduce your systems liability. They also can be overridden by local protocol for incidents which involve enviromental conditions or other factors which could change response. We have been using it in our area for several years it works great.