Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 I thought I'd try my hand?at giving y'all a cardiology scenario. You are dispatched to an 85 y/o female complaining of heart palpitations.? Upon arrival, you find a woman sitting in a chair.? Skin pink, warm, and dry.? Initial vitals are HR 220, BP 96/60, RR 28.? Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are Coumadin, Lasix, Captopril, and Nitro (taken PRN). NKDA She states she was watching TV and she got upset, then started experiencing palpitations. After she rested for 30 minutes, she called 911 after the palpitations did not clear up.? At this point, EKG shows a narrow complex tachycardia at 220 bpm. 12 lead shows no ST elevation/depression nor does it indicate any history of ischemia/infarction.? End-tidal carbon dioxide is 34. You're in an outlying suburban area with progressive ALS protocols. The closest hospital is a community hospital about 15 minutes away with limited ICU/cardiac capability.? Big City Regional is about a 35 minute drive.? Of course, you have aeromedical available, if you want to risk Dr. Bledsoe's ire. It's your call. Run it. -Wes Ogilvie, MPA, JD, LP -Attorney/Licensed Paramedic -Licensed and Sanitized for your protection ________________________________________________________________________ More new features than ever. Check out the new AOL Mail ! - http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid=aolcmp0\ 0050000000003 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 Give her Cardizem then hang a drip. Cardiology scenario I thought I'd try my hand?at giving y'all a cardiology scenario. You are dispatched to an 85 y/o female complaining of heart palpitations.? Upon arrival, you find a woman sitting in a chair.? Skin pink, warm, and dry.? Initial vitals are HR 220, BP 96/60, RR 28.? Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are Coumadin, Lasix, Captopril, and Nitro (taken PRN). NKDA She states she was watching TV and she got upset, then started experiencing palpitations. After she rested for 30 minutes, she called 911 after the palpitations did not clear up.? At this point, EKG shows a narrow complex tachycardia at 220 bpm. 12 lead shows no ST elevation/depression nor does it indicate any history of ischemia/infarction.? End-tidal carbon dioxide is 34. You're in an outlying suburban area with progressive ALS protocols. The closest hospital is a community hospital about 15 minutes away with limited ICU/cardiac capability.? Big City Regional is about a 35 minute drive.? Of course, you have aeromedical available, if you want to risk Dr. Bledsoe's ire. It's your call. Run it. -Wes Ogilvie, MPA, JD, LP -Attorney/Licensed Paramedic -Licensed and Sanitized for your protection __________________________________________________________ More new features than ever. Check out the new AOL Mail ! - http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid=aolcmp0\ 0050000000003 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 Well, since the patient is relatively stable, I would move to the truck, start as large a bore IV in an AC as possible, put on O2 initiate transport to the community hospital. Since the patient is older I think the longer drive to Big City Regional is not appropriate. During transport if the patient deteriorates I would perform cardioversion. Leave the adenocard or cardizem for the folks at the hospital. I chose the community hospital as the ED physician stabilize and control the rate under close supervision then transfer to Big City Regional if needed. Rick ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of Wes Ogilvie Sent: Friday, November 30, 2007 10:19 AM To: texasems-l ; Paramedicine Subject: Cardiology scenario I thought I'd try my hand?at giving y'all a cardiology scenario. You are dispatched to an 85 y/o female complaining of heart palpitations.? Upon arrival, you find a woman sitting in a chair.? Skin pink, warm, and dry.? Initial vitals are HR 220, BP 96/60, RR 28.? Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are Coumadin, Lasix, Captopril, and Nitro (taken PRN). NKDA She states she was watching TV and she got upset, then started experiencing palpitations. After she rested for 30 minutes, she called 911 after the palpitations did not clear up.? At this point, EKG shows a narrow complex tachycardia at 220 bpm. 12 lead shows no ST elevation/depression nor does it indicate any history of ischemia/infarction.? End-tidal carbon dioxide is 34. You're in an outlying suburban area with progressive ALS protocols. The closest hospital is a community hospital about 15 minutes away with limited ICU/cardiac capability.? Big City Regional is about a 35 minute drive.? Of course, you have aeromedical available, if you want to risk Dr. Bledsoe's ire. It's your call. Run it. -Wes Ogilvie, MPA, JD, LP -Attorney/Licensed Paramedic -Licensed and Sanitized for your protection __________________________________________________________ More new features than ever. Check out the new AOL Mail ! - http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid=aolcmp0\ 0050000000003 <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid=aolcmp\ 00050000000003> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 I would start high-flow oxygen via non rebreather mask. I would then attempt a vagal menuver on her to try to calm her heart rate down while either me or my advanced partner starts a large bore IV in AC. If no success with vagal menuvers I would administer 6mg Adenosine rapid push with 10cc flush, Begin rapid transport... Try one or two additional pushes of 12mg Adenosine if unsuccessful (spaced a few minutes within each dose). If unsuccessful do syncronized cardiovert. --- " , Rick " wrote: > Well, since the patient is relatively stable, I > would move to the truck, start as large a bore IV in > an AC as possible, put on O2 initiate transport to > the community hospital. Since the patient is older I > think the longer drive to Big City Regional is not > appropriate. During transport if the patient > deteriorates I would perform cardioversion. Leave > the adenocard or cardizem for the folks at the > hospital. I chose the community hospital as the ED > physician stabilize and control the rate under close > supervision then transfer to Big City Regional if > needed. > Rick > > ________________________________ > > From: texasems-l > [mailto:texasems-l ] On Behalf Of Wes > Ogilvie > Sent: Friday, November 30, 2007 10:19 AM > To: texasems-l ; > Paramedicine > Subject: Cardiology scenario > > > > > I thought I'd try my hand?at giving y'all a > cardiology scenario. > > You are dispatched to an 85 y/o female complaining > of heart palpitations.? Upon arrival, you find a > woman sitting in a chair.? Skin pink, warm, and > dry.? Initial vitals are HR 220, BP 96/60, RR 28.? > Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are > Coumadin, Lasix, Captopril, and Nitro (taken PRN). > NKDA > > She states she was watching TV and she got upset, > then started experiencing palpitations. After she > rested for 30 minutes, she called 911 after the > palpitations did not clear up.? At this point, EKG > shows a narrow complex tachycardia at 220 bpm. 12 > lead shows no ST elevation/depression nor does it > indicate any history of ischemia/infarction.? > End-tidal carbon dioxide is 34. > > You're in an outlying suburban area with progressive > ALS protocols. The closest hospital is a community > hospital about 15 minutes away with limited > ICU/cardiac capability.? Big City Regional is about > a 35 minute drive.? Of course, you have aeromedical > available, if you want to risk Dr. Bledsoe's ire. > > It's your call. Run it. > > -Wes Ogilvie, MPA, JD, LP > -Attorney/Licensed Paramedic > -Licensed and Sanitized for your protection > > __________________________________________________________ > More new features than ever. Check out the new AOL > Mail ! - > http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid=aolcmp0\ 0050000000003 > <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid=aolcmp\ 00050000000003> > > > [Non-text portions of this message have been > removed] > > > > > > > > [Non-text portions of this message have been > removed] > > ________________________________________________________________________________\ ____ Get easy, one-click access to your favorites. Make Yahoo! your homepage. http://www.yahoo.com/r/hs Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 Why? Patient is stable and 85 year olds don't do well in asystole. If she becomes unstable certainly cardiovert. Read the insert for adenocard, states to use caution in elderly patients, and 85 is definitely elderly. Just cause we have red or orange patches we don't have to perform every intervention or give every drug in the book. Rick ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of Jimenez Sent: Friday, November 30, 2007 11:11 AM To: texasems-l Subject: RE: Cardiology scenario I would start high-flow oxygen via non rebreather mask. I would then attempt a vagal menuver on her to try to calm her heart rate down while either me or my advanced partner starts a large bore IV in AC. If no success with vagal menuvers I would administer 6mg Adenosine rapid push with 10cc flush, Begin rapid transport... Try one or two additional pushes of 12mg Adenosine if unsuccessful (spaced a few minutes within each dose). If unsuccessful do syncronized cardiovert. --- " , Rick " <rick.moore@... <mailto:rick.moore%40triadhospitals.com> > wrote: > Well, since the patient is relatively stable, I > would move to the truck, start as large a bore IV in > an AC as possible, put on O2 initiate transport to > the community hospital. Since the patient is older I > think the longer drive to Big City Regional is not > appropriate. During transport if the patient > deteriorates I would perform cardioversion. Leave > the adenocard or cardizem for the folks at the > hospital. I chose the community hospital as the ED > physician stabilize and control the rate under close > supervision then transfer to Big City Regional if > needed. > Rick > > ________________________________ > > From: texasems-l <mailto:texasems-l%40yahoogroups.com> > [mailto:texasems-l <mailto:texasems-l%40yahoogroups.com> ] On Behalf Of Wes > Ogilvie > Sent: Friday, November 30, 2007 10:19 AM > To: texasems-l <mailto:texasems-l%40yahoogroups.com> ; > Paramedicine <mailto:Paramedicine%40yahoogroups.com> > Subject: Cardiology scenario > > > > > I thought I'd try my hand?at giving y'all a > cardiology scenario. > > You are dispatched to an 85 y/o female complaining > of heart palpitations.? Upon arrival, you find a > woman sitting in a chair.? Skin pink, warm, and > dry.? Initial vitals are HR 220, BP 96/60, RR 28.? > Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are > Coumadin, Lasix, Captopril, and Nitro (taken PRN). > NKDA > > She states she was watching TV and she got upset, > then started experiencing palpitations. After she > rested for 30 minutes, she called 911 after the > palpitations did not clear up.? At this point, EKG > shows a narrow complex tachycardia at 220 bpm. 12 > lead shows no ST elevation/depression nor does it > indicate any history of ischemia/infarction.? > End-tidal carbon dioxide is 34. > > You're in an outlying suburban area with progressive > ALS protocols. The closest hospital is a community > hospital about 15 minutes away with limited > ICU/cardiac capability.? Big City Regional is about > a 35 minute drive.? Of course, you have aeromedical > available, if you want to risk Dr. Bledsoe's ire. > > It's your call. Run it. > > -Wes Ogilvie, MPA, JD, LP > -Attorney/Licensed Paramedic > -Licensed and Sanitized for your protection > > __________________________________________________________ > More new features than ever. Check out the new AOL > Mail ! - > http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid =aolcmp00050000000003 <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci d=aolcmp00050000000003> > <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci d=aolcmp00050000000003 <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci d=aolcmp00050000000003> > > > > [Non-text portions of this message have been > removed] > > > > > > > > [Non-text portions of this message have been > removed] > > __________________________________________________________ Get easy, one-click access to your favorites. Make Yahoo! your homepage. http://www.yahoo.com/r/hs <http://www.yahoo.com/r/hs> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 Well, first of all I don't know of any patient who DID do well in Asystole. You would say you would rather have a patient that has been SVT's 30+ minutes and have a weak heart in the first place and risk a 30-60 minute transport and just cardiovert if her condition deteriotes? I became a red patch to help people, which means doing proper interventions. better than just watching soemone start to circle with an hour into that narrow-band tachy. With the first dose of Adenocard you can try slowing the heart rate down just enough to tell if it is Atrial in nature VS ventricular in nature. Then you can treat appropriately. I'm a paramedic, not a sit-down-and-watch guy. Also, cannot find the contraindication based on age part on the packet insert, just a general cuation because the study group is not big enough. It does say that general clinical experiences suggest that there is not much difference between the response of geriatric use vs. younger groups. But, if your protocols say to go straight to cardiovert, thats cool too. She was probably watching the UT game. But also, everything depends on where you work and where you go to school. - --- " , Rick " wrote: > Why? Patient is stable and 85 year olds don't do > well in asystole. If > she becomes unstable certainly cardiovert. Read the > insert for > adenocard, states to use caution in elderly > patients, and 85 is > definitely elderly. > Just cause we have red or orange patches we don't > have to perform every > intervention or give every drug in the book. > Rick > > ________________________________ > > From: texasems-l > [mailto:texasems-l ] On > Behalf Of Jimenez > Sent: Friday, November 30, 2007 11:11 AM > To: texasems-l > Subject: RE: Cardiology scenario > > > > I would start high-flow oxygen via non rebreather > mask. I would then attempt a vagal menuver on her to > try to calm her heart rate down while either me or > my > advanced partner starts a large bore IV in AC. > > If no success with vagal menuvers I would administer > 6mg Adenosine rapid push with 10cc flush, > > Begin rapid transport... > > Try one or two additional pushes of 12mg Adenosine > if > unsuccessful (spaced a few minutes within each > dose). > > If unsuccessful do syncronized cardiovert. > > --- " , Rick " <rick.moore@... > <mailto:rick.moore%40triadhospitals.com> > > wrote: > > > Well, since the patient is relatively stable, I > > would move to the truck, start as large a bore IV > in > > an AC as possible, put on O2 initiate transport to > > the community hospital. Since the patient is older > I > > think the longer drive to Big City Regional is not > > appropriate. During transport if the patient > > deteriorates I would perform cardioversion. Leave > > the adenocard or cardizem for the folks at the > > hospital. I chose the community hospital as the ED > > physician stabilize and control the rate under > close > > supervision then transfer to Big City Regional if > > needed. > > Rick > > > > ________________________________ > > > > From: texasems-l > <mailto:texasems-l%40yahoogroups.com> > > > [mailto:texasems-l > <mailto:texasems-l%40yahoogroups.com> ] On Behalf Of > Wes > > Ogilvie > > Sent: Friday, November 30, 2007 10:19 AM > > To: texasems-l > <mailto:texasems-l%40yahoogroups.com> ; > > Paramedicine > <mailto:Paramedicine%40yahoogroups.com> > > Subject: Cardiology scenario > > > > > > > > > > I thought I'd try my hand?at giving y'all a > > cardiology scenario. > > > > You are dispatched to an 85 y/o female complaining > > of heart palpitations.? Upon arrival, you find a > > woman sitting in a chair.? Skin pink, warm, and > > dry.? Initial vitals are HR 220, BP 96/60, RR 28.? > > Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are > > Coumadin, Lasix, Captopril, and Nitro (taken PRN). > > NKDA > > > > She states she was watching TV and she got upset, > > then started experiencing palpitations. After she > > rested for 30 minutes, she called 911 after the > > palpitations did not clear up.? At this point, EKG > > shows a narrow complex tachycardia at 220 bpm. 12 > > lead shows no ST elevation/depression nor does it > > indicate any history of ischemia/infarction.? > > End-tidal carbon dioxide is 34. > > > > You're in an outlying suburban area with > progressive > > ALS protocols. The closest hospital is a community > > hospital about 15 minutes away with limited > > ICU/cardiac capability.? Big City Regional is > about > > a 35 minute drive.? Of course, you have > aeromedical > > available, if you want to risk Dr. Bledsoe's ire. > > > > It's your call. Run it. > > > > -Wes Ogilvie, MPA, JD, LP > > -Attorney/Licensed Paramedic > > -Licensed and Sanitized for your protection > > > > > __________________________________________________________ > > More new features than ever. Check out the new AOL > > Mail ! - > > > http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid > =aolcmp00050000000003 > <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci > d=aolcmp00050000000003> > > > <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci > d=aolcmp00050000000003 > <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci > d=aolcmp00050000000003> > > > > > > > [Non-text portions of this message have been > > removed] > > > > > > > > > > > > > > > > [Non-text portions of this message have been > > removed] > > > > > > __________________________________________________________ > Get easy, one-click access to your favorites. > Make Yahoo! your homepage. > http://www.yahoo.com/r/hs > <http://www.yahoo.com/r/hs> > > > > > > > [Non-text portions of this message have been > removed] > > ________________________________________________________________________________\ ____ Get easy, one-click access to your favorites. 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Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 I agree that we are paramedics to help people, but remember our first rule, " do no harm " . Some times not performing an intervention is the better part of valor and the only way to do no harm. We need to understand that and not feel like a plain vanilla basic transport is outside our realm. In my job as trauma program coordinator I work with surgeons and ED physicians. Two of the most aggressive groups you will ever work with and albeit reluctantly even these aggressive surgeons are coming around to the thinking that some things need to be watched. 5-10 years ago, overnight observation of a fractured liver or spleen was unheard of, now rushing these patients to the OR and cutting is not the first line treatment in many cases. With the ED docs, RSI has been bumped down on the list in favor of a trial of CPAP. The bottom line is that my plumber has a truck full of expensive tools and machines, but he doesn't use them on every job and neither should we. As someone mentioned yesterday in a thread, even the red patch says EMT in the middle of it. Remember Paramedics save lives, basics save paramedics. Rick ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of Jimenez Sent: Friday, November 30, 2007 11:55 AM To: texasems-l Subject: RE: Cardiology scenario Well, first of all I don't know of any patient who DID do well in Asystole. You would say you would rather have a patient that has been SVT's 30+ minutes and have a weak heart in the first place and risk a 30-60 minute transport and just cardiovert if her condition deteriotes? I became a red patch to help people, which means doing proper interventions. better than just watching soemone start to circle with an hour into that narrow-band tachy. With the first dose of Adenocard you can try slowing the heart rate down just enough to tell if it is Atrial in nature VS ventricular in nature. Then you can treat appropriately. I'm a paramedic, not a sit-down-and-watch guy. Also, cannot find the contraindication based on age part on the packet insert, just a general cuation because the study group is not big enough. It does say that general clinical experiences suggest that there is not much difference between the response of geriatric use vs. younger groups. But, if your protocols say to go straight to cardiovert, thats cool too. She was probably watching the UT game. But also, everything depends on where you work and where you go to school. - --- " , Rick " <rick.moore@... <mailto:rick.moore%40triadhospitals.com> > wrote: > Why? Patient is stable and 85 year olds don't do > well in asystole. If > she becomes unstable certainly cardiovert. Read the > insert for > adenocard, states to use caution in elderly > patients, and 85 is > definitely elderly. > Just cause we have red or orange patches we don't > have to perform every > intervention or give every drug in the book. > Rick > > ________________________________ > > From: texasems-l <mailto:texasems-l%40yahoogroups.com> > [mailto:texasems-l <mailto:texasems-l%40yahoogroups.com> ] On > Behalf Of Jimenez > Sent: Friday, November 30, 2007 11:11 AM > To: texasems-l <mailto:texasems-l%40yahoogroups.com> > Subject: RE: Cardiology scenario > > > > I would start high-flow oxygen via non rebreather > mask. I would then attempt a vagal menuver on her to > try to calm her heart rate down while either me or > my > advanced partner starts a large bore IV in AC. > > If no success with vagal menuvers I would administer > 6mg Adenosine rapid push with 10cc flush, > > Begin rapid transport... > > Try one or two additional pushes of 12mg Adenosine > if > unsuccessful (spaced a few minutes within each > dose). > > If unsuccessful do syncronized cardiovert. > > --- " , Rick " <rick.moore@... <mailto:rick.moore%40triadhospitals.com> > <mailto:rick.moore%40triadhospitals.com> > > wrote: > > > Well, since the patient is relatively stable, I > > would move to the truck, start as large a bore IV > in > > an AC as possible, put on O2 initiate transport to > > the community hospital. Since the patient is older > I > > think the longer drive to Big City Regional is not > > appropriate. During transport if the patient > > deteriorates I would perform cardioversion. Leave > > the adenocard or cardizem for the folks at the > > hospital. I chose the community hospital as the ED > > physician stabilize and control the rate under > close > > supervision then transfer to Big City Regional if > > needed. > > Rick > > > > ________________________________ > > > > From: texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com> > > > [mailto:texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com> ] On Behalf Of > Wes > > Ogilvie > > Sent: Friday, November 30, 2007 10:19 AM > > To: texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com> ; > > Paramedicine <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> > > Subject: Cardiology scenario > > > > > > > > > > I thought I'd try my hand?at giving y'all a > > cardiology scenario. > > > > You are dispatched to an 85 y/o female complaining > > of heart palpitations.? Upon arrival, you find a > > woman sitting in a chair.? Skin pink, warm, and > > dry.? Initial vitals are HR 220, BP 96/60, RR 28.? > > Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are > > Coumadin, Lasix, Captopril, and Nitro (taken PRN). > > NKDA > > > > She states she was watching TV and she got upset, > > then started experiencing palpitations. After she > > rested for 30 minutes, she called 911 after the > > palpitations did not clear up.? At this point, EKG > > shows a narrow complex tachycardia at 220 bpm. 12 > > lead shows no ST elevation/depression nor does it > > indicate any history of ischemia/infarction.? > > End-tidal carbon dioxide is 34. > > > > You're in an outlying suburban area with > progressive > > ALS protocols. The closest hospital is a community > > hospital about 15 minutes away with limited > > ICU/cardiac capability.? Big City Regional is > about > > a 35 minute drive.? Of course, you have > aeromedical > > available, if you want to risk Dr. Bledsoe's ire. > > > > It's your call. Run it. > > > > -Wes Ogilvie, MPA, JD, LP > > -Attorney/Licensed Paramedic > > -Licensed and Sanitized for your protection > > > > > __________________________________________________________ > > More new features than ever. Check out the new AOL > > Mail ! - > > > http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?ncid <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci d> > =aolcmp00050000000003 > <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci > > d=aolcmp00050000000003> > > > <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci > > d=aolcmp00050000000003 > <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci <http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm?nci > > d=aolcmp00050000000003> > > > > > > > [Non-text portions of this message have been > > removed] > > > > > > > > > > > > > > > > [Non-text portions of this message have been > > removed] > > > > > > __________________________________________________________ > Get easy, one-click access to your favorites. > Make Yahoo! your homepage. > http://www.yahoo.com/r/hs <http://www.yahoo.com/r/hs> > <http://www.yahoo.com/r/hs <http://www.yahoo.com/r/hs> > > > > > > > > [Non-text portions of this message have been > removed] > > __________________________________________________________ Get easy, one-click access to your favorites. 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Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 Yeah, I don't think we should be using plumbers tools too... I agree, and yes I did say that... my progression list was listed from basic interventions to ALS... I think that if I didn't try anything here where I work, I would get reemed by everyone I passed.. and then my commander's would go to work on me. Again, its all about who's progressive and who's aggressive. Anyway, I'm stopping now. --- " , Rick " wrote: > I agree that we are paramedics to help people, but > remember our first > rule, " do no harm " . Some times not performing an > intervention is the > better part of valor and the only way to do no harm. > We need to > understand that and not feel like a plain vanilla > basic transport is > outside our realm. In my job as trauma program > coordinator I work with > surgeons and ED physicians. Two of the most > aggressive groups you will > ever work with and albeit reluctantly even these > aggressive surgeons are > coming around to the thinking that some things need > to be watched. 5-10 > years ago, overnight observation of a fractured > liver or spleen was > unheard of, > now rushing these patients to the OR and cutting is > not the first line > treatment in many cases. With the ED docs, RSI has > been bumped down on > the list in favor of a trial of CPAP. > The bottom line is that my plumber has a truck full > of expensive tools > and machines, but he doesn't use them on every job > and neither should > we. As someone mentioned yesterday in a thread, even > the red patch says > EMT in the middle of it. Remember Paramedics save > lives, basics save > paramedics. > Rick > > ________________________________ > > From: texasems-l > [mailto:texasems-l ] On > Behalf Of Jimenez > Sent: Friday, November 30, 2007 11:55 AM > To: texasems-l > Subject: RE: Cardiology scenario > > > > Well, first of all I don't know of any patient who > DID > do well in Asystole. > > You would say you would rather have a patient that > has > been SVT's 30+ minutes and have a weak heart in the > first place and risk a 30-60 minute transport and > just > cardiovert if her condition deteriotes? > > I became a red patch to help people, which means > doing > proper interventions. better than just watching > soemone start to circle with an hour into that > narrow-band tachy. With the first dose of Adenocard > you can try slowing the heart rate down just enough > to > tell if it is Atrial in nature VS ventricular in > nature. Then you can treat appropriately. > > I'm a paramedic, not a sit-down-and-watch guy. Also, > cannot find the contraindication based on age part > on > the packet insert, just a general cuation because > the > study group is not big enough. It does say that > general clinical experiences suggest that there is > not > much difference between the response of geriatric > use > vs. younger groups. > > But, if your protocols say to go straight to > cardiovert, thats cool too. She was probably > watching > the UT game. > > But also, everything depends on where you work and > where you go to school. > > - > > --- " , Rick " <rick.moore@... > <mailto:rick.moore%40triadhospitals.com> > > wrote: > > > Why? Patient is stable and 85 year olds don't do > > well in asystole. If > > she becomes unstable certainly cardiovert. Read > the > > insert for > > adenocard, states to use caution in elderly > > patients, and 85 is > > definitely elderly. > > Just cause we have red or orange patches we don't > > have to perform every > > intervention or give every drug in the book. > > Rick > > > > ________________________________ > > > > From: texasems-l > <mailto:texasems-l%40yahoogroups.com> > > > [mailto:texasems-l > <mailto:texasems-l%40yahoogroups.com> ] On > > Behalf Of Jimenez > > Sent: Friday, November 30, 2007 11:11 AM > > To: texasems-l > <mailto:texasems-l%40yahoogroups.com> > > Subject: RE: Cardiology scenario > > > > > > > > I would start high-flow oxygen via non rebreather > > mask. I would then attempt a vagal menuver on her > to > > try to calm her heart rate down while either me or > > my > > advanced partner starts a large bore IV in AC. > > > > If no success with vagal menuvers I would > administer > > 6mg Adenosine rapid push with 10cc flush, > > > > Begin rapid transport... > > > > Try one or two additional pushes of 12mg Adenosine > > if > > unsuccessful (spaced a few minutes within each > > dose). > > > > If unsuccessful do syncronized cardiovert. > > > > --- " , Rick " <rick.moore@... > <mailto:rick.moore%40triadhospitals.com> > > <mailto:rick.moore%40triadhospitals.com> > > > wrote: > > > > > Well, since the patient is relatively stable, I > > > would move to the truck, start as large a bore > IV > > in > > > an AC as possible, put on O2 initiate transport > to > > > the community hospital. Since the patient is > older > > I > > > think the longer drive to Big City Regional is > not > > > appropriate. During transport if the patient > > > deteriorates I would perform cardioversion. > Leave > > > the adenocard or cardizem for the folks at the > > > hospital. I chose the community hospital as the > ED > > > physician stabilize and control the rate under > > close > > > supervision then transfer to Big City Regional > if > > > needed. > > > Rick > > > > > > ________________________________ > > > > > > From: texasems-l > <mailto:texasems-l%40yahoogroups.com> > > <mailto:texasems-l%40yahoogroups.com> > > > > > [mailto:texasems-l > <mailto:texasems-l%40yahoogroups.com> > > <mailto:texasems-l%40yahoogroups.com> ] On Behalf > Of > > Wes > > > Ogilvie > > > Sent: Friday, November 30, 2007 10:19 AM > > > To: texasems-l > <mailto:texasems-l%40yahoogroups.com> > > > <mailto:texasems-l%40yahoogroups.com> ; > > > Paramedicine > <mailto:Paramedicine%40yahoogroups.com> > > > <mailto:Paramedicine%40yahoogroups.com> > > > Subject: Cardiology scenario > > > > > > > > > > > > > > > I thought I'd try my hand?at giving y'all a > > > cardiology scenario. > > > > > > You are dispatched to an 85 y/o female > complaining > === message truncated === ________________________________________________________________________________\ ____ Be a better pen pal. 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Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 Everybody seems to have missed that this patient has a Hx of atrial fib and is on coumadin. Therefore, it is quite likely that she is not in PSVT but in a rapid a fib, in which case adenosine would not be the drug of choice. So blindly following what " seems " to be the operative algorithm might not be the best thing for the patient. I would try some additional leads and perhaps a change in speed to attempt to see if this is in fact a fib before I started pushing anything. If she becomes unstable, then cardiovert. At 85 years old, the only vagal maneuver I would try would be to ask her to cough forcefully. Under no circumstances should her carotids be messed with. A smart doctor once told me, " As long as your patient is doing well, try not to do anything that will worsen her condition. " Sometimes doing nothing is the best plan, until a better picture of what is happening can be obtained. Gene G. In a message dated 11/30/07 12:48:13 PM, rick.moore@... writes: > > How sad is it that we have to perform potentially harmful interventions > on stable patients to keep our co-workers, commanders and medical > directors happy. What ever happened to clinical judgment? > > ____________ ________ ________ _ > > From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On > Behalf Of Jimenez > Sent: Friday, November 30, 2007 12:43 PM > To: texasems-l@yahoogrotexasem > Subject: RE: Cardiology scenario > > Yeah, I don't think we should be using plumbers tools > too... > > I agree, and yes I did say that... my progression list > was listed from basic interventions to ALS... I think > that if I didn't try anything here where I work, I > would get reemed by everyone I passed.. and then my > commander's would go to work on me. > > Again, its all about who's progressive and who's > aggressive. Anyway, I'm stopping now. > > > > --- " , Rick " <rick.moore@... > <mailto:rick.mailto:rick.<wbrmailto:ric> > > wrote: > > > I agree that we are paramedics to help people, but > > remember our first > > rule, " do no harm " . Some times not performing an > > intervention is the > > better part of valor and the only way to do no harm. > > We need to > > understand that and not feel like a plain vanilla > > basic transport is > > outside our realm. In my job as trauma program > > coordinator I work with > > surgeons and ED physicians. Two of the most > > aggressive groups you will > > ever work with and albeit reluctantly even these > > aggressive surgeons are > > coming around to the thinking that some things need > > to be watched. 5-10 > > years ago, overnight observation of a fractured > > liver or spleen was > > unheard of, > > now rushing these patients to the OR and cutting is > > not the first line > > treatment in many cases. With the ED docs, RSI has > > been bumped down on > > the list in favor of a trial of CPAP. > > The bottom line is that my plumber has a truck full > > of expensive tools > > and machines, but he doesn't use them on every job > > and neither should > > we. As someone mentioned yesterday in a thread, even > > the red patch says > > EMT in the middle of it. Remember Paramedics save > > lives, basics save > > paramedics. > > Rick > > > > ____________ ________ ________ _ > > > > From: texasems-l@yahoogrotexasem <mailto:texasems-mailto:texasems-mai> > > > [mailto:texasems-l@yahoogrotexasem > <mailto:texasems-mailto:texasems-mai> ] On > > Behalf Of Jimenez > > Sent: Friday, November 30, 2007 11:55 AM > > To: texasems-l@yahoogrotexasem <mailto:texasems-mailto:texasems-mai> > > Subject: RE: Cardiology scenario > > > > > > > > Well, first of all I don't know of any patient who > > DID > > do well in Asystole. > > > > You would say you would rather have a patient that > > has > > been SVT's 30+ minutes and have a weak heart in the > > first place and risk a 30-60 minute transport and > > just > > cardiovert if her condition deteriotes? > > > > I became a red patch to help people, which means > > doing > > proper interventions. better than just watching > > soemone start to circle with an hour into that > > narrow-band tachy. With the first dose of Adenocard > > you can try slowing the heart rate down just enough > > to > > tell if it is Atrial in nature VS ventricular in > > nature. Then you can treat appropriately. > > > > I'm a paramedic, not a sit-down-and- I'm a paramedic > > cannot find the contraindication based on age part > > on > > the packet insert, just a general cuation because > > the > > study group is not big enough. It does say that > > general clinical experiences suggest that there is > > not > > much difference between the response of geriatric > > use > > vs. younger groups. > > > > But, if your protocols say to go straight to > > cardiovert, thats cool too. She was probably > > watching > > the UT game. > > > > But also, everything depends on where you work and > > where you go to school. > > > > - > > > > --- " , Rick " <rick.moore@... > <mailto:rick.mailto:rick.<wbrmailto:ric> > > <mailto:rick.mailto:rick.<wbrmailto:ric> > > > wrote: > > > > > Why? Patient is stable and 85 year olds don't do > > > well in asystole. If > > > she becomes unstable certainly cardiovert. Read > > the > > > insert for > > > adenocard, states to use caution in elderly > > > patients, and 85 is > > > definitely elderly. > > > Just cause we have red or orange patches we don't > > > have to perform every > > > intervention or give every drug in the book. > > > Rick > > > > > > ____________ ________ ________ _ > > > > > > From: texasems-l@yahoogrotexasem > <mailto:texasems-mailto:texasems-mai> > > <mailto:texasems-mailto:texasems-mai> > > > > > [mailto:texasems-l@yahoogrotexasem > <mailto:texasems-mailto:texasems-mai> > > <mailto:texasems-mailto:texasems-mai> ] On > > > Behalf Of Jimenez > > > Sent: Friday, November 30, 2007 11:11 AM > > > To: texasems-l@yahoogrotexasem <mailto:texasems-mailto:texasems-mai> > > > <mailto:texasems-mailto:texasems-mai> > > > Subject: RE: Cardiology scenario > > > > > > > > > > > > I would start high-flow oxygen via non rebreather > > > mask. I would then attempt a vagal menuver on her > > to > > > try to calm her heart rate down while either me or > > > my > > > advanced partner starts a large bore IV in AC. > > > > > > If no success with vagal menuvers I would > > administer > > > 6mg Adenosine rapid push with 10cc flush, > > > > > > Begin rapid transport... > > > > > > Try one or two additional pushes of 12mg Adenosine > > > if > > > unsuccessful (spaced a few minutes within each > > > dose). > > > > > > If unsuccessful do syncronized cardiovert. > > > > > > --- " , Rick " <rick.moore@... > <mailto:rick.mailto:rick.<wbrmailto:ric> > > <mailto:rick.mailto:rick.<wbrmailto:ric> > > > <mailto:rick.mailto:rick.<wbrmailto:ric> > > > > wrote: > > > > > > > Well, since the patient is relatively stable, I > > > > would move to the truck, start as large a bore > > IV > > > in > > > > an AC as possible, put on O2 initiate transport > > to > > > > the community hospital. Since the patient is > > older > > > I > > > > think the longer drive to Big City Regional is > > not > > > > appropriate. During transport if the patient > > > > deteriorates I would perform cardioversion. > > Leave > > > > the adenocard or cardizem for the folks at the > > > > hospital. I chose the community hospital as the > > ED > > > > physician stabilize and control the rate under > > > close > > > > supervision then transfer to Big City Regional > > if > > > > needed. > > > > Rick > > > > > > > > ____________ ________ ________ _ > > > > > > > > From: texasems-l@yahoogrotexasem > <mailto:texasems-mailto:texasems-mai> > > <mailto:texasems-mailto:texasems-mai> > > > <mailto:texasems-mailto:texasems-mai> > > > > > > > [mailto:texasems-l@yahoogrotexasem > <mailto:texasems-mailto:texasems-mai> > > <mailto:texasems-mailto:texasems-mai> > > > <mailto:texasems-mailto:texasems-mai> ] On Behalf > > Of > > > Wes > > > > Ogilvie > > > > Sent: Friday, November 30, 2007 10:19 AM > > > > To: texasems-l@yahoogrotexasem > <mailto:texasems-mailto:texasems-mai> > > <mailto:texasems-mailto:texasems-mai> > > > > > <mailto:texasems-mailto:texasems-mai> ; > > > > Paramedicine@ParamedicinePar > <mailto:Paramedicinmailto:Paramedicmai> > > <mailto:Paramedicinmailto:Paramedicmai> > > > > > <mailto:Paramedicinmailto:Paramedicmai> > > > > Subject: Cardiology scenario > > > > > > > > > > > > > > > > > > > > I thought I'd try my hand?at giving y'all a > > > > cardiology scenario. > > > > > > > > You are dispatched to an 85 y/o female > > complaining > > > === message truncated === > > ____________ ________ ________ ________ ________ ________ > Be a better pen pal. > Text or chat with friends inside Yahoo! Mail. See how. > http://overview.http://overhttp <http://overview.http://overhttp> > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 How sad is it that we have to perform potentially harmful interventions on stable patients to keep our co-workers, commanders and medical directors happy. What ever happened to clinical judgment? ________________________________ From: texasems-l [mailto:texasems-l ] On Behalf Of Jimenez Sent: Friday, November 30, 2007 12:43 PM To: texasems-l Subject: RE: Cardiology scenario Yeah, I don't think we should be using plumbers tools too... I agree, and yes I did say that... my progression list was listed from basic interventions to ALS... I think that if I didn't try anything here where I work, I would get reemed by everyone I passed.. and then my commander's would go to work on me. Again, its all about who's progressive and who's aggressive. Anyway, I'm stopping now. --- " , Rick " <rick.moore@... <mailto:rick.moore%40triadhospitals.com> > wrote: > I agree that we are paramedics to help people, but > remember our first > rule, " do no harm " . Some times not performing an > intervention is the > better part of valor and the only way to do no harm. > We need to > understand that and not feel like a plain vanilla > basic transport is > outside our realm. In my job as trauma program > coordinator I work with > surgeons and ED physicians. Two of the most > aggressive groups you will > ever work with and albeit reluctantly even these > aggressive surgeons are > coming around to the thinking that some things need > to be watched. 5-10 > years ago, overnight observation of a fractured > liver or spleen was > unheard of, > now rushing these patients to the OR and cutting is > not the first line > treatment in many cases. With the ED docs, RSI has > been bumped down on > the list in favor of a trial of CPAP. > The bottom line is that my plumber has a truck full > of expensive tools > and machines, but he doesn't use them on every job > and neither should > we. As someone mentioned yesterday in a thread, even > the red patch says > EMT in the middle of it. Remember Paramedics save > lives, basics save > paramedics. > Rick > > ________________________________ > > From: texasems-l <mailto:texasems-l%40yahoogroups.com> > [mailto:texasems-l <mailto:texasems-l%40yahoogroups.com> ] On > Behalf Of Jimenez > Sent: Friday, November 30, 2007 11:55 AM > To: texasems-l <mailto:texasems-l%40yahoogroups.com> > Subject: RE: Cardiology scenario > > > > Well, first of all I don't know of any patient who > DID > do well in Asystole. > > You would say you would rather have a patient that > has > been SVT's 30+ minutes and have a weak heart in the > first place and risk a 30-60 minute transport and > just > cardiovert if her condition deteriotes? > > I became a red patch to help people, which means > doing > proper interventions. better than just watching > soemone start to circle with an hour into that > narrow-band tachy. With the first dose of Adenocard > you can try slowing the heart rate down just enough > to > tell if it is Atrial in nature VS ventricular in > nature. Then you can treat appropriately. > > I'm a paramedic, not a sit-down-and-watch guy. Also, > cannot find the contraindication based on age part > on > the packet insert, just a general cuation because > the > study group is not big enough. It does say that > general clinical experiences suggest that there is > not > much difference between the response of geriatric > use > vs. younger groups. > > But, if your protocols say to go straight to > cardiovert, thats cool too. She was probably > watching > the UT game. > > But also, everything depends on where you work and > where you go to school. > > - > > --- " , Rick " <rick.moore@... <mailto:rick.moore%40triadhospitals.com> > <mailto:rick.moore%40triadhospitals.com> > > wrote: > > > Why? Patient is stable and 85 year olds don't do > > well in asystole. If > > she becomes unstable certainly cardiovert. Read > the > > insert for > > adenocard, states to use caution in elderly > > patients, and 85 is > > definitely elderly. > > Just cause we have red or orange patches we don't > > have to perform every > > intervention or give every drug in the book. > > Rick > > > > ________________________________ > > > > From: texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com> > > > [mailto:texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com> ] On > > Behalf Of Jimenez > > Sent: Friday, November 30, 2007 11:11 AM > > To: texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com> > > Subject: RE: Cardiology scenario > > > > > > > > I would start high-flow oxygen via non rebreather > > mask. I would then attempt a vagal menuver on her > to > > try to calm her heart rate down while either me or > > my > > advanced partner starts a large bore IV in AC. > > > > If no success with vagal menuvers I would > administer > > 6mg Adenosine rapid push with 10cc flush, > > > > Begin rapid transport... > > > > Try one or two additional pushes of 12mg Adenosine > > if > > unsuccessful (spaced a few minutes within each > > dose). > > > > If unsuccessful do syncronized cardiovert. > > > > --- " , Rick " <rick.moore@... <mailto:rick.moore%40triadhospitals.com> > <mailto:rick.moore%40triadhospitals.com> > > <mailto:rick.moore%40triadhospitals.com> > > > wrote: > > > > > Well, since the patient is relatively stable, I > > > would move to the truck, start as large a bore > IV > > in > > > an AC as possible, put on O2 initiate transport > to > > > the community hospital. Since the patient is > older > > I > > > think the longer drive to Big City Regional is > not > > > appropriate. During transport if the patient > > > deteriorates I would perform cardioversion. > Leave > > > the adenocard or cardizem for the folks at the > > > hospital. I chose the community hospital as the > ED > > > physician stabilize and control the rate under > > close > > > supervision then transfer to Big City Regional > if > > > needed. > > > Rick > > > > > > ________________________________ > > > > > > From: texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com> > > <mailto:texasems-l%40yahoogroups.com> > > > > > [mailto:texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com> > > <mailto:texasems-l%40yahoogroups.com> ] On Behalf > Of > > Wes > > > Ogilvie > > > Sent: Friday, November 30, 2007 10:19 AM > > > To: texasems-l <mailto:texasems-l%40yahoogroups.com> > <mailto:texasems-l%40yahoogroups.com> > > > <mailto:texasems-l%40yahoogroups.com> ; > > > Paramedicine <mailto:Paramedicine%40yahoogroups.com> > <mailto:Paramedicine%40yahoogroups.com> > > > <mailto:Paramedicine%40yahoogroups.com> > > > Subject: Cardiology scenario > > > > > > > > > > > > > > > I thought I'd try my hand?at giving y'all a > > > cardiology scenario. > > > > > > You are dispatched to an 85 y/o female > complaining > === message truncated === __________________________________________________________ Be a better pen pal. 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Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 " With the first dose of Adenocard you can try slowing the heart rate down just enough to tell if it is Atrial in nature VS ventricular in nature. Then you can treat appropriately. " isn't it if the complex is WIDE then it's ventricular in origin or supraventricular with aberrant conduction. this scenario said it was narrow. and can't you do a 12 lead and tell which is which?? jim davis Jimenez wrote: Well, first of all I don't know of any patient who DID do well in Asystole. You would say you would rather have a patient that has been SVT's 30+ minutes and have a weak heart in the first place and risk a 30-60 minute transport and just cardiovert if her condition deteriotes? I became a red patch to help people, which means doing proper interventions. better than just watching soemone start to circle with an hour into that narrow-band tachy. With the first dose of Adenocard you can try slowing the heart rate down just enough to tell if it is Atrial in nature VS ventricular in nature. Then you can treat appropriately. I'm a paramedic, not a sit-down-and-watch guy. Also, cannot find the contraindication based on age part on the packet insert, just a general cuation because the study group is not big enough. It does say that general clinical experiences suggest that there is not much difference between the response of geriatric use vs. younger groups. But, if your protocols say to go straight to cardiovert, thats cool too. She was probably watching the UT game. But also, everything depends on where you work and where you go to school. - --- " , Rick " wrote: > Why? Patient is stable and 85 year olds don't do > well in asystole. If > she becomes unstable certainly cardiovert. Read the > insert for > adenocard, states to use caution in elderly > patients, and 85 is > definitely elderly. > Just cause we have red or orange patches we don't > have to perform every > intervention or give every drug in the book. > Rick > > ________________________________ > > From: texasems-l > [mailto:texasems-l ] On > Behalf Of Jimenez > Sent: Friday, November 30, 2007 11:11 AM > To: texasems-l > Subject: RE: Cardiology scenario > > > > I would start high-flow oxygen via non rebreather > mask. I would then attempt a vagal menuver on her to > try to calm her heart rate down while either me or > my > advanced partner starts a large bore IV in AC. > > If no success with vagal menuvers I would administer > 6mg Adenosine rapid push with 10cc flush, > > Begin rapid transport... > > Try one or two additional pushes of 12mg Adenosine > if > unsuccessful (spaced a few minutes within each > dose). > > If unsuccessful do syncronized cardiovert. > > --- " , Rick " <rick.moore@... > <mailto:rick.moore%40triadhospitals.com> > > wrote: > > > Well, since the patient is relatively stable, I > > would move to the truck, start as large a bore IV > in > > an AC as possible, put on O2 initiate transport to > > the community hospital. Since the patient is older > I > > think the longer drive to Big City Regional is not > > appropriate. During transport if the patient > > deteriorates I would perform cardioversion. Leave > > the adenocard or cardizem for the folks at the > > hospital. I chose the community hospital as the ED > > physician stabilize and control the rate under > close > > supervision then transfer to Big City Regional if > > needed. > > Rick > > > > ________________________________ > > > > From: texasems-l > <mailto:texasems-l%40yahoogroups.com> > > > [mailto:texasems-l > <mailto:texasems-l%40yahoogroups.com> ] On Behalf Of > Wes > > Ogilvie > > Sent: Friday, November 30, 2007 10:19 AM > > To: texasems-l > <mailto:texasems-l%40yahoogroups.com> ; > > Paramedicine > <mailto:Paramedicine%40yahoogroups.com> > > Subject: Cardiology scenario > > > > > > > > > > I thought I'd try my hand?at giving y'all a > > cardiology scenario. > > > > You are dispatched to an 85 y/o female complaining > > of heart palpitations.? Upon arrival, you find a > > woman sitting in a chair.? Skin pink, warm, and > > dry.? Initial vitals are HR 220, BP 96/60, RR 28.? > > Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are > > Coumadin, Lasix, Captopril, and Nitro (taken PRN). > > NKDA > > > > She states she was watching TV and she got upset, > > then started experiencing palpitations. After she > > rested for 30 minutes, she called 911 after the > > palpitations did not clear up.? At this point, EKG > > shows a narrow complex tachycardia at 220 bpm. 12 > > lead shows no ST elevation/depression nor does it > > indicate any history of ischemia/infarction.? > > End-tidal carbon dioxide is 34. > > > > You're in an outlying suburban area with > progressive > > ALS protocols. The closest hospital is a community > > hospital about 15 minutes away with limited > > ICU/cardiac capability.? Big City Regional is > about > > a 35 minute drive.? Of course, you have > aeromedical > > available, if you want to risk Dr. Bledsoe's ire. > > > > It's your call. Run it. > > > > -Wes Ogilvie, MPA, JD, LP > > -Attorney/Licensed Paramedic > > -Licensed and Sanitized for your protection > > > > > __________________________________________________________ > > More new features than ever. 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Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 Supra-ventricular... my bad. Slow it down enough to try to figure out if it's a-fib or regular SVT. A-fib does not necesarilly HAVE to be " irregularly irregular " . Check this article out... (totally off topic) Emergency Responders Face Deep Aid Cuts http://hosted.ap.org/dynamic/stories/S/SECURITY_GRANTS?SITE=AP & SECTION=HOME & TEMP\ LATE=DEFAULT & CTIME=2007-11-30-16-41-59 --- james davis wrote: > " With the first dose of Adenocard > you can try slowing the heart rate down just enough > to > tell if it is Atrial in nature VS ventricular in > nature. Then you can treat appropriately. " > > isn't it if the complex is WIDE then it's > ventricular in origin or supraventricular with > aberrant conduction. this scenario said it was > narrow. and can't you do a 12 lead and tell which is > which?? > > jim davis > > > Jimenez wrote: > Well, first of all I don't know of any > patient who DID > do well in Asystole. > > You would say you would rather have a patient that > has > been SVT's 30+ minutes and have a weak heart in the > first place and risk a 30-60 minute transport and > just > cardiovert if her condition deteriotes? > > I became a red patch to help people, which means > doing > proper interventions. better than just watching > soemone start to circle with an hour into that > narrow-band tachy. With the first dose of Adenocard > you can try slowing the heart rate down just enough > to > tell if it is Atrial in nature VS ventricular in > nature. Then you can treat appropriately. > > I'm a paramedic, not a sit-down-and-watch guy. Also, > cannot find the contraindication based on age part > on > the packet insert, just a general cuation because > the > study group is not big enough. It does say that > general clinical experiences suggest that there is > not > much difference between the response of geriatric > use > vs. younger groups. > > But, if your protocols say to go straight to > cardiovert, thats cool too. She was probably > watching > the UT game. > > But also, everything depends on where you work and > where you go to school. > > - > > --- " , Rick " > wrote: > > > Why? Patient is stable and 85 year olds don't do > > well in asystole. If > > she becomes unstable certainly cardiovert. Read > the > > insert for > > adenocard, states to use caution in elderly > > patients, and 85 is > > definitely elderly. > > Just cause we have red or orange patches we don't > > have to perform every > > intervention or give every drug in the book. > > Rick > > > > ________________________________ > > > > From: texasems-l > > [mailto:texasems-l ] On > > Behalf Of Jimenez > > Sent: Friday, November 30, 2007 11:11 AM > > To: texasems-l > > Subject: RE: Cardiology scenario > > > > > > > > I would start high-flow oxygen via non rebreather > > mask. I would then attempt a vagal menuver on her > to > > try to calm her heart rate down while either me or > > my > > advanced partner starts a large bore IV in AC. > > > > If no success with vagal menuvers I would > administer > > 6mg Adenosine rapid push with 10cc flush, > > > > Begin rapid transport... > > > > Try one or two additional pushes of 12mg Adenosine > > if > > unsuccessful (spaced a few minutes within each > > dose). > > > > If unsuccessful do syncronized cardiovert. > > > > --- " , Rick " <rick.moore@... > > <mailto:rick.moore%40triadhospitals.com> > > > wrote: > > > > > Well, since the patient is relatively stable, I > > > would move to the truck, start as large a bore > IV > > in > > > an AC as possible, put on O2 initiate transport > to > > > the community hospital. Since the patient is > older > > I > > > think the longer drive to Big City Regional is > not > > > appropriate. During transport if the patient > > > deteriorates I would perform cardioversion. > Leave > > > the adenocard or cardizem for the folks at the > > > hospital. I chose the community hospital as the > ED > > > physician stabilize and control the rate under > > close > > > supervision then transfer to Big City Regional > if > > > needed. > > > Rick > > > > > > ________________________________ > > > > > > From: texasems-l > > <mailto:texasems-l%40yahoogroups.com> > > > > > [mailto:texasems-l > > <mailto:texasems-l%40yahoogroups.com> ] On Behalf > Of > > Wes > > > Ogilvie > > > Sent: Friday, November 30, 2007 10:19 AM > > > To: texasems-l > > <mailto:texasems-l%40yahoogroups.com> ; > > > Paramedicine > > <mailto:Paramedicine%40yahoogroups.com> > > > Subject: Cardiology scenario > > > > > > > > > > > > > > > I thought I'd try my hand?at giving y'all a > > > cardiology scenario. > > > > > > You are dispatched to an 85 y/o female > complaining > > > of heart palpitations.? Upon arrival, you find a > > > woman sitting in a chair.? Skin pink, warm, and > > > dry.? Initial vitals are HR 220, BP 96/60, RR > 28.? > > > Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are > > > Coumadin, Lasix, Captopril, and Nitro (taken > PRN). > > > NKDA > > > > > > She states she was watching TV and she got > upset, > > > then started experiencing palpitations. After > she > > > rested for 30 minutes, she called 911 after the > > > palpitations did not clear up.? At this point, > EKG > > > shows a narrow complex tachycardia at 220 bpm. > 12 > > > lead shows no ST elevation/depression nor does > it > > > indicate any history of ischemia/infarction.? > > > End-tidal carbon dioxide is 34. > > > > > > You're in an outlying suburban area with > > progressive > > > ALS protocols. The closest hospital is a > community > > > hospital about 15 minutes away with limited > > > ICU/cardiac capability.? Big City Regional is > > about > > > a 35 minute drive.? Of course, you have > > aeromedical > > > available, if you want to risk Dr. Bledsoe's > ire. > > > > > > It's your call. Run it. > > > > > > -Wes Ogilvie, MPA, JD, LP > > > -Attorney/Licensed Paramedic > > > -Licensed and Sanitized for your protection > > > > > > > === message truncated === ________________________________________________________________________________\ ____ Never miss a thing. Make Yahoo your home page. http://www.yahoo.com/r/hs Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 Thought I'd add my 2 cents for what it's worth. Judging from some of the answers I've seen, I can guess that some of my learned collegues don't have just a whole lot of experience dealing with geriatric patients. First off, this lady is very anxious (happens when you get far enough along in years to see the Reaper around every corner) evidence, the 28 resp. If you go for high flow O2 with an NRB, you're just going to increase that anxiety level. Use a cannula at 2-3 LPM. TAKE SOME TIME WITH THE PATIENT. Dont get in a rush. A little quiet conversation and reassuring goes a long way with our older patients. Talk to her, reassure her, and try to get her calmed down and concentrating on her breathing. This will reduce her anxiety level and may actually resolve the situation. I've actually seen it happen. If the calming doesn't work, you're going to have to do something. While she is stable now, an 85 yr old with a 220 heart rate isnt going to remain stable long. Try the vagal manuevers and hope they work, but be prepared if they don't. Next, there are some that want to start large bore IVs. Folks, with an 85 yr old, you could consider yourself lucky to get a 20 ga. Take what you can get and use it. Since the patient has a history of A Fib, it's a safe bet that she's got it again. You can try the Adenosine and see if it slows the heart rate so you can see for sure, but it doesn't happen often. It's not going to hurt her, so give it a try. If you are unable to rule out A Fib, treat her for her history. Give her the Diltiazem. My bet is that will work. In my experience, it usually does(I personally wouldn't waste time with the Adenosine, but that's just me). I know what the book says about cardioversion, but with a geriatric patient, cardioversion goes WAY down on my list. I would reserve that as a last resort, and would be careful with that in any A fib patient anyway. Just loading her up and running to the hospital may work in some cases, but there times when you need to act in the best interests of the patient. Dealing with small hospitals every day, I can tell you what will happen before the Doc treats her. She'll get a 12 lead, labs, chest Xray and anything else he can think of before he decides anything. Mean time, your little old lady is getting closer to the big one. You need to use what you've learned and help people you can help. This one that you can. I don't know if this is the answer you were looking for Wes, but I'm just telling you what I've learned from my experiences ( and I DO have a few of those at my advanced age LOL). Learn you patients, learn your system, and treat your patients like you'd want someone treating your Grandma. Ok, there's my 2 cents. Somebody elses turn. Joe T > > > I thought I'd try my hand?at giving y'all a cardiology scenario. > > You are dispatched to an 85 y/o female complaining of heart palpitations.? Upon arrival, you find a woman sitting in a chair.? Skin pink, warm, and dry.? Initial vitals are HR 220, BP 96/60, RR 28.? Prior HX of A-Fib, HTN, TIA, and CHF.? Meds are Coumadin, Lasix, Captopril, and Nitro (taken PRN). NKDA > > She states she was watching TV and she got upset, then started experiencing palpitations. After she rested for 30 minutes, she called 911 after the palpitations did not clear up.? At this point, EKG shows a narrow complex tachycardia at 220 bpm. 12 lead shows no ST elevation/depression nor does it indicate any history of ischemia/infarction.? End-tidal carbon dioxide is 34. > > You're in an outlying suburban area with progressive ALS protocols. The closest hospital is a community hospital about 15 minutes away with limited ICU/cardiac capability.? Big City Regional is about a 35 minute drive.? Of course, you have aeromedical available, if you want to risk Dr. Bledsoe's ire. > > It's your call. Run it. > > -Wes Ogilvie, MPA, JD, LP > -Attorney/Licensed Paramedic > -Licensed and Sanitized for your protection > > _____________________________________________________________________ ___ > More new features than ever. Check out the new AOL Mail ! - http://o.aolcdn.com/cdn.webmail.aol.com/mailtour/aol/en-us/text.htm? ncid=aolcmp00050000000003 > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 You mean you're not able to handle a Rolling Code Brown? GG > > >>At 85 years old, the only vagal maneuver I would try would be to ask her > to > cough forcefully. Under no circumstances should her carotids be messed with.< > < > > Note to all providers: Never ask anyone to bear down if they have stool > softeners or laxatives on their medication record. > > Just a helpful tip from your Uncle ... > > -- > Grayson, CCEMT-P, etc. > MEDIC Training Solutions > http://www.medictrahttp://www.medihttp > > > ************************************** Check out AOL's list of 2007's hottest products. (http://money.aol.com/special/hot-products-2007?NCID=aoltop00030000000001) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 >>With the first dose of Adenocard you can try slowing the heart rate down just enough to tell if it is Atrial in nature VS ventricular in nature. Then you can treat appropriately.<< More likely is Adenosine slowing the rate just enough to unmask the underlying atrial activity and allow you to determine whether the tachycardia is *reentrant* or *automatic focus* in nature. Couple points to add: If the regular dosing regimen of adenosine is ineffective, cardioversion ain't likely to work well, either. When it comes right down to it, they work pretty much the same way: terminate *all* conduction momentarily, in the hopes that a normally functioning intrinsic pacemaker will take over. If an abnormally fast pacemaker *is* the problem, you can give all the adenosine you want and/or shock repeatedly, and the problem will probably regenerate. For *those* tachycardias, you need blockade. In theory, the way to clinically (as opposed to, say, an EP study) distinguish between the two is by reserving its response to Adenosine. I tend to agree with Rick , however. We need to limit the number of selective cardiotoxins we administer, and get more comfortable with cardioversion. If you have made the clinical decision that your patient needs conversion *now*, as opposed to 10 minutes from now, that treatment probably needs to be the therapeutic electrocution. -- Grayson, CCEMT-P, etc. MEDIC Training Solutions http://www.medictrainingsolutions.com/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 >>Slow it down enough to try to figure out if it's a-fib or regular SVT. A-fib does not necesarilly HAVE to be " irregularly irregular " .<< Yeah, it does. It's just that sometimes the rate is fast enough that the irregularity is best recognized with calipers, not eyeballs. <grin> -- Grayson, CCEMT-P, etc. MEDIC Training Solutions http://www.medictrainingsolutions.com/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted November 30, 2007 Report Share Posted November 30, 2007 >>At 85 years old, the only vagal maneuver I would try would be to ask her to cough forcefully. Under no circumstances should her carotids be messed with.<< Note to all providers: Never ask anyone to bear down if they have stool softeners or laxatives on their medication record. Just a helpful tip from your Uncle ... -- Grayson, CCEMT-P, etc. MEDIC Training Solutions http://www.medictrainingsolutions.com/ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 2, 2007 Report Share Posted December 2, 2007 If it is too fast(symptomatic) slow it down. If it is too slow (symptomatic) speed it up. I would say this patient is borderline symptomatic with the BP. I would definately do High flow 02. though she is elderly, since rhythm sustained for thirty min, it needs to be slowed or it will soon become a rhythm that is all too familiar. __________________________ Vagal man. attempt, possible adenosine, but with the HX of a-fib, possible Cardizem. Good Scenario! > > You mean you're not able to handle a Rolling Code Brown? > > GG > > > > > > > >>At 85 years old, the only vagal maneuver I would try would be to ask her > > to > > cough forcefully. Under no circumstances should her carotids be messed with.< > > < > > > > Note to all providers: Never ask anyone to bear down if they have stool > > softeners or laxatives on their medication record. > > > > Just a helpful tip from your Uncle ... > > > > -- > > Grayson, CCEMT-P, etc. > > MEDIC Training Solutions > > http://www.medictrahttp://www.medihttp > > > > > > > > > > > ************************************** > Check out AOL's list of 2007's hottest > products. > > (http://money.aol.com/special/hot-products-2007? NCID=aoltop00030000000001) > > > Quote Link to comment Share on other sites More sharing options...
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