58 year old female CC: Chest pain - Conclusion

Tom B | 10:31 AM | | 2 comments

Here's the conclusion to the 58 year old female with chest pain and left bundle branch block.

To refresh your memory here is the 12-lead ECG.


And for those of you who requested lead V4R.



This ECG meets all 3 of Sgarbossa's criteria to identify acute STEMI in the presence of left bundle branch block.

Keep in mind, it only has to meet one criterion in one lead!

(Please note: One criterion has been modified from its original form. Instead of discordant ST-elevation > 5 mm we are looking for discordant ST-elevation > 0.2 the depth of the S-wave. Credit to Dr. Smith of Dr. Smith's ECG Blog.)




Angiography revealed 100% occlusion of the LCX and 99% occlusion of the RCA.

Thanks to everyone who commented on the case!

See also:

AMI in the presence of LBBB - Sgarbossa's Criteria Part I




58 year old female CC: Chest pain

Tom B | 9:27 PM | | 4 comments

Here's another case study from an international reader who wishes to remain anonymous.

Presenting Complaint - Chest Pain

History of Present Complaint - 58 year old female, nil cardiac history, mild smoker, social drinker and overweight.

Complaining of acute central chest pain @ rest. Awoken by pain.

On Arrival - Sat upright on settee (Editor's note: One of you Brits will have to interpret that for me!)

On examination:

Alert, orientated and communicable (GCS 15)
Pale, cool dry skin.

Nil SOB, clear bi-lateral air entry - nil adventitious breath sounds
R/R 19, SpO2 99%

H/R 68 and irregular, BP 125/74

Temp 36.8
B.M 7.2 (Editor's note: B.M. is BGL measured in millimoles. 1 mmol/L of glucose is equivalent to 18 mg/dL. Hence, this patient's sugar is about 130).

C/O chest pain.

O - Acute. Awoken from sleep.
P - Nothing makes pain better. Not affected by breathing
Q - Non specific compressing type pain
R - Central chest pain radiating left arm
S - Pain score 6/10
T - 30 mins
I - No pain intervention sought.

Slight nausea, nil vomit

The cardiac monitor is attached.


A 12-lead ECG is captured.



Once again, I am impressed at the power of Web 2.0.!

Getting case studies like this from thousands of miles away is a real privilege and it makes me very happy to be able to share them with my colleagues from around the world!

This ECG meets all 3 of a certain criteria.

What criteria are we talking about and how would you treat this patient?

While you're at it, please CLICK HERE if you missed my previous post and cast your vote!

Chronicles of EMS - Here Are the Finalists! VOTE NOW!

Tom B | 10:01 AM | | 0 comments

As you may have heard, the finalists are in for the Chronicles of EMS "Change the Name" competition! The field has now been narrowed from over 500 entries to just 5!

It just so happens that my girlfriend Kelly is one of the finalists.

Now, I don't want to influence your decision in any way....


create avatar


So please CLICK HERE to cast your vote NOW!

Select one of the following:

Beyond the Lights and Sirens

Mobile Medicine

Frontline Medicine

Medicine in the Streets

Real Life, Real Emergencies


Again, just choose from your heart.

Don't be influenced by the fact that this could lead to a trip to Europe for yours truly! :)

See also:

Chronicles of EMS - "Change the Name" Competition! 

Grand Rounds - 2

Adam Thompson, EMT-P | 11:25 AM | | 1 comments

In an effort to spread the knowledge of EMS blogs, I am authoring a monthly column on EMSresponder.com.

Check out Grand Rounds.  The first one is more of an introduction to EMS blogs.  Next month I will summarize the posts a bit more.  If you are interested in me mentioning your blog, shoot me an email at paramedicine101@gmail.com.

Intubation Education

Rogue Medic | 4:33 PM | , , | 3 comments





In the article I was writing about[1] (Experts Debate Paramedic Intubation) in my post Experts Debate Paramedic Intubation - JEMS.com, there is a bit of defense of the status quo in intubation and intubation training.


We get hung up on many of the same problems. We think that there is one right way to do things, rather than accept that we are adapting what we do to the different circumstances we are faced with.

We act as if the OR (Operating Room) is the only place that we can obtain good practice. There is no evidence to support this.

There is nothing to show that OR training is superior to morgue training and mannequin training, but we act as if the decreased availability of OR time is the only reason medics can't intubate competently.

We act as if the only problem with the way we are teaching paramedic school is that the students are not learning. As if this is not a reflection on the teaching.

Teaching means providing information to students in a way that helps the students to understand. If the students do not understand, the teacher did not teach.

Perhaps you do not believe that we do a poor job at intubation education.


Results

Nine hundred twenty-six patients had an attempted intubation. Methods of airway management were determined for 97.5% (825/846) of those transported to a hospital and 33.8% (27/80) of those who died in the field. For transported patients, 74.8% were successfully intubated, 20% had a failed intubation, 5.2% had a malpositioned tube on arrival to the ED, and 0.6% had another method of airway management used. Malpositioned tubes were significantly more common in pediatric patients (13.0%, compared with 4.0% for nonpediatric patients).

Conclusions

Overall intubation success was low, and consistent with previously published series. The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies. Our data support the need for ongoing monitoring of EMS providers' practices of endotracheal intubation.[2]



Those numbers may be considered good in many areas - batting average, picking winning stocks, votes in an election. When it comes to airway management, we would be more appropriate if we described failure rates.

These failure rates are unacceptably high.

Overall intubation success was low, and consistent with previously published series.

In other words, the authors believe that this is the expected result of the way we train paramedics to intubate.

Can anyone show that this is not true?


The frequency of malpositioned ETT was unacceptably high, and also consistent with prior studies.


This is the expected result of the way we train paramedics to intubate.


Our data support the need for ongoing monitoring of EMS providers' practices of endotracheal intubation.





5.2% had a malpositioned tube on arrival to the ED.

5.2% Unrecognized Esophageal Intubations!


Ongoing monitoring Watching is not enough.

We need to dramatically change the way we handle intubation education.


Footnotes:


[1] Experts Debate Paramedic Intubation - Should paramedics continue to intubate?
JEMS.com
Bryan E. Bledsoe, DO, FACEP, FAAEM | Darren Braude, MD, MPH, FACEP, EMT-P | David K. Tan, MD, FAAEM, EMT-T | Henry Wang, MD, MS | Marc Eckstein, MD, MPH, FACEP | Marvin Wayne, MD, FACEP, FAAEM | William E. Gandy, D, LP, NREMT-P
Thursday, July 1, 2010
Article



[2] A prospective multicenter evaluation of prehospital airway management performance in a large metropolitan region.
Denver Metro Airway Study Group.
Colwell CB, Cusick JM, Hawkes AP, Luyten DR, McVaney KE, Pineda GV, Riccio JC, Severyn FA, Vellman WP, Heller J, Ship J, Gunter J, Battan K, Kozlowski M, Kanowitz A.
Prehosp Emerg Care. 2009 Jul-Sep;13(3):304-10.
PMID: 19499465 [PubMed - in process]


.

Videos: Kill some time

Adam Thompson, EMT-P | 4:15 PM | , | 0 comments

I'm going to be on vacation for a week, in Chicago. In the meantime, here are some videos to kill some time. I am not responsible for the content.



























Treating Tachycardia

Adam Thompson, EMT-P | 8:15 PM | , , | 4 comments


Treating Tachycardia
By Adam Thompson, EMT-P


Tachycardia simply means a faster heart rate than normal.  With the sinoatrial node, which is the heart's inborn pacemaker, the intrinsic rate is between 60 and 100 beats per minute.  When the rate exceeds 100 beats per minute, tachycardia is present.

When treating tachycardia, it is important to first consider a compensatory cause.  The body tends to use an increased heart rate as a frequent compensatory mechanism when it senses decreased perfusion.  Two of the best dysrhythmics in the EMT and paramedic's tool box are OXYGEN and NORMAL SALINE. Both of these treatments should be attempted prior to using any other medication.  It is not advantageous to eliminate a compensatory tachycardia in a patient who needs it to perfuse.  Locating the cause of the decreased perfusion would be optimal.

Another thing to consider is the patient's hemodynamic stability.  With organized tachycardic rhythms in unstable patients, synchronized cardioversion is indicated.  There seems to be a fear amongst prehospital providers when it comes to shocking people.  The paramedic seems to be much more comfortable giving anti-arhythmic/dysrhythmic medications than they do performing cardioversion.  This is in-fact backwards thinking.  Consider Kelly Grayson's outlook on dysrhythmic drugs--they are selective cardiotoxins.  First off, they are not naturally found in the body.  Second, they metabolize over time and the reaction can be unpredictable.  Thirdly, they are used to counteract cellular depolarization.  Do you know what happens in the absence of cellular depolarization in the myocardium?  Asystole--not a common side effect, but it drives home the point doesn't it?.  Other complications, like high-grade atrioventricular blocks, and long QT syndrome may also occur.  Conversely, synchronized cardioversion doesn't have nearly as many unwanted effects.  It works fast, and goes away.  The medication you should be considering, is some sort of sedative or benzodiazapine prior to cardioversion.

Next, after determining the patient's hemodynamic stability, the width of the QRS should be considered. If the patient is stable, and they are in a sustained tachycardia, dysrhythmic medications can be considered.  It is important to determine the width of the QRS, because medications like Cardizem (diltiazem), or Adenocard (adenosine) that may be administered to narrow complex rhythms, can effectively KILL people with wide QRS rhythms.  Notice that there is not a 'ventricular tachycardia' algorithm?  It states 'Wide QRS', and lists 'uncertain rhythm' below.  This is an important concept.  If it is wide, and you are uncertain of the origin, it is ventricular tachycardia until conclusively proven otherwise.  Another reason that it is a WCT guideline and not a ventricular tachycardia guideline is because of conditions like WPW (wolff parkinson white syndrome).  With WPW, a delta wave may be present causing widening of the QRS complex.  This is important because adenosine, and Cardizem should not be administered to patients with WPW.  There is controversy regarding whether Amiodarone is safe with WPW, but as of now the American Heart Association considers it a safe option.

A wide QRS complex is considered greater than 120 ms or 0.12 seconds or 3 small boxes.


Points to remember:

  • O2 & fluids for compensatory tachycardia
  •  Synchronized cardioversion is the SAFER option
  • If QRS is wide treat as V-tach
Note: Torsades de Pointes should not be treated with Amiodarone.  This can cause lengthening of the QT interval, and subsequently a worse arrhythmia.  








Brugada Criteria.  This should only be used to confirm ventricular origin.  Not to rule it out.  

View more documents from Adam Thompson.

Videos: Acute Coronary Syndrome

Adam Thompson, EMT-P | 8:08 PM | , | 2 comments

Some stuff for you visual learners, enjoy.


This one ends abruptly, but makes a point that I like to stress, DIAPHORESIS is BAD!

Sorry for this one, but I thought it was funny






In the following video, the presenter has used some of Tom B's teaching aids to teach Sgarbossa's criteria.  I pronounce it with the 'S' by the way.  

Also check these out - video , & video

Drug Profile: Ketamine

Adam Thompson, EMT-P | 12:44 PM | , | 0 comments

Ketamine 

By Adam Thompson, EMT-P



Since my beginning in the world of prehospital medicine, which wasn't too long ago, I have heard more and more about a particular drug.  I have attended critical care and emergency medicine conferences and the same has been true.  Ketamine seems to have become a favorite amongst many physicians.  I have never administered the drug myself, but it has made its way into some prehospital standing orders, and with reason.  


Ketamine Hydrochloride
Non-barbiturate anesthetic 

Mechanism of action:
  • Creates a state of dissociation from reality.  
  • Catecholamines (epinephrine & norepinephrine) are released.  
  • Spinal reflexes are reduced.


Indications:
  • Indicated for anesthesia when cardiovascular depression must be avoided.  
  • A commonly used induction agent to facilitate endotracheal intubation.

Contraindications:
  • Hypersensitivity to Ketamine
  • Increased intracranial pressure
  • Hypertension
  • Aneurysm
  • Thyrotoxicosis (hyperthyroid)
  • Congestive heart failure
  • Angina
  • Psychotic disorders
  • Pregnancy
So there are a lot of contraindications that happen to be conditions that we see commonly.  But think about what they are, and what the side effects are of the other drugs that we administer for similar indications.  Almost every other medication decreases blood pressure.  Ketamine actually increases it, so it has its place.  

Side Effects:
  • Hallucinations
  • Vivid dreams
  • Hypertension
  • Increased cardiac output
  • Tachycardia
  • Paradoxical direct myocardial depression
  • Increased ICP
  • Tonic-clonic movements

Overdose:

      With high doses or rapid administration, respiratory depression may occur.



Dosage:
  • Oral: Pediatric 6 - 10 mg/kg
  • Intramuscular: 3 - 8 mg/kg
  • Intravenous: Pediatric 0.5 - 2 mg/kg, Adult 1 - 4.5 mg/kg
Onset is about 1-2 minutes if given I.V., and 3-8 minutes if given I.M.



Some research:

The effect of combined treatment with morphine sulphate and low-dose ketamine in a prehospital setting [1] 
Conclusion 
We conclude that morphine sulphate with addition of small doses of ketamine provide adequate pain relief in patients with bone fractures, with an increase in systolic blood pressure, but without significant side effects.
Anesthesia in prehospital emergencies and in the emergency department. [2]
Abstract
PURPOSE OF REVIEW: Recently, notable progress has been made in the field of anesthesia drugs and airway management. RECENT FINDINGS: Anesthesia in prehospital emergencies and in the emergency department is reviewed and guidelines are discussed. SUMMARY: Preoxygenation should be performed with high-flow oxygen delivered through a tight-fitting face mask with a reservoir. Ketamine may be the induction agent of choice in hemodynamically unstable patients. The rocuronium antagonist sugammadex may have the potential to make rocuronium a first-line neuromuscular blocking agent in emergency induction. Experienced healthcare providers may consider prehospital anesthesia induction. Moderately experienced healthcare providers should optimize oxygenation, hasten hospital transfer and only try to intubate a patient whose life is threatened. When intubation fails twice, ventilation should be performed with an alternative supraglottic airway or a bag-valve-mask device. Lesser experienced healthcare providers should completely refrain from intubation, optimize oxygenation, hasten hospital transfer and ventilate patients only in life-threatening circumstances with a supraglottic airway or a bag-valve-mask device. Senior help should be sought early. In a 'cannot ventilate-cannot intubate' situation, a supraglottic airway should be employed and, if ventilation is still unsuccessful, a surgical airway should be performed. Capnography should be used in every ventilated patient. Clinical practice is essential to retain anesthesia and airway management skills.
Pre-hospital use of ketamine for analgesia and procedural sedation [3]
Abstract
The safe delivery of adequate analgesia and appropriate sedation is a priority in prehospital care. The use of ketamine is described for analgesia and sedation in 1030 trauma patients in a physician-led prehospital trauma service. Ketamine was mainly used in awake non-trapped patients with blunt trauma for procedural sedation and analgesia. Detailed database searches did not demonstrate loss of airway, oxygen desaturation or clinically significant emergence reactions after ketamine administration. Ketamine is relatively safe when used by physicians in prehospital trauma care.
Ketamine for prehospital use: new look at an old drug. [4]
Abstract
INTRODUCTION: Ketamine has been used extensively for analgesia and anesthesia in many situations, including disaster surgery where extra personnel and advanced monitoring are not available. There are many features of ketamine that seem to make it an ideal drug for prehospital use. The reported use of ketamine in the prehospital environment is limited, however. The purpose of this study is to review the experience in the use of ketamine in a regional air ambulance service and suggest indications for its use in the prehospital setting. METHODS: This was a retrospective study of all patients transported by a regional aeromedical program. Patients were included in this study if the crew had used ketamine at any time during the flight. Data regarding the transport collected included patient age, type of transport, indications for ketamine use, and adverse reactions. RESULTS: During the period studied, ketamine was used in 40 patients. The age range was 2 months to 75 years. The indications and situations requiring use were varied and included both trauma and medical patients. Hypotension with need for analgesia, agitation or combativeness and intact airway, or pain unresponsive to narcotic medications were the most common indications for use. Ketamine was used both intravenous and intramuscular, even without intravenous access. There were no adverse reactions. CONCLUSIONS: Ketamine is an ideal drug for use in many prehospital situations. Our experience suggests that it is safe, effective, and may be more appropriate than drugs currently used by prehospital providers.


ClinCon 2010

Adam Thompson, EMT-P | 11:55 AM | , | 2 comments



Hello to all of our loyal readers.  It's Adam here and I am sorry for the long periods of nothing to read.  It was that time of year again, and I was preparing for the ClinCon conference.  If you are unfamiliar with it, head over to their WEBSITE.

The reason this takes up so much of my time is because I am part of my agency's ALS competition team.  We compete in these scenario-based competitions.  It's somewhat of a game.  Imagine the worst possible call you could ever run, and multiply that by five.  That tends to be the types of scenarios the sadist that come up with the challenges think up.




This was my fourth year competing at ClinCon and my team had remained winless.  There are two days of competitions with some of the best teams in the country competing.  On the first day is the preliminary round, which every team competes in.  A team is made of three crew members, and one alternate whom usually holds the video camera.

Preliminary scenario

Bus crash:

  • The first five minutes was a START Triage scenario which required each team to go through a number of cards that included patient type and vital signs.  Each card had a number and you had to assign a color (red, yellow, green, or black) to the corresponding numbers.  
  • We are then rushed in, to what is deemed the yellow treatment area.  Within this area was a mother holding a baby, and a patient complaining of burning eyes. 
  • A good sample history and assessment uncovers the cause of the burning eyes which is chlorine.  The patient also presented with wheezing.
  • The baby was who was actually a green, was not suppose to be re-triaged, but kept with mom instead.
  • The mother ends up having hypertension, and then postpartum eclampsia.  Her seizures would persist until Magnesium was administered.
  • At about the ten minute mark, another patient presents.  He is nearly unresponsive, and shows signs of a cardiac contusion and cardiac tamponade.  
Treatments they were looking for:
  • Rapid full-body assessments on every patient.
  • Re-triage all patients red.
  • Flush eyes of chlorine exposed patient
  • Treat wheezing with bronchodilator 
  • Once wheezing subsides rales present - treat with Lasix or CPAP
  • Treat Eclampsia with Magnesium Sulfate
  • Recognize pericardial tamponade 
Treatments we did:
  • Got 100% of the assessments
  • Flushed eyes of chlorine exposure
  • Provided high-flow O2, then albuterol, the nebulized Sodium Bicarbonate.
  • Recognized the low acuity of the baby and kept it with mom
  • Treated mom with benzodiazepines then Mag.
  • Recognized Beck's triad & electrical alternans (cardiac tamponade) and performed a pericardiocentesis.  
So we didn't do exactly everything that they were looking for.  Even though we completely resolved the tamponade, there were no points for the percardiocentesis because they said "no one does that".  Um, we do.  In fact, all arrest thought to be due to blunt force thoracic trauma receives three needles in their chest.  One of them in the heart.  

We were concerned that the other 40 teams would have done better and we wouldn't make it into the top five this year.  This concern subsided once we saw the results.  We got second over all and made it into the finals once again.  Even though, this is just a scenario-based competition and not a real sport, there is a lot of pride.  These teams that compete in these challenges take it very seriously and are impressively good.  We were thrilled to have done so well.  


The Finals

Political rally:

The bus that crashed in the preliminaries was to be headed to a political rally that set the scene for the finals.  The finals are performed in front of a live audience at the venue.  Prior to entering the scenario, each team was shown a video.  It is of the political rally, and portrayed a possible explosion.
  • Three initial patients.
  • A room filled with picket signs and full bottles labeled dihydrogen monoxide
  • A single black box about the size of a shoe box was present in the middle of the room.
  • First patient was in V-fib arrest, and had a dialysis shunt.  CPR was being poorly performed by a distractor.  
A distractor is any actor in the scenario that is not a patient.  Dihydrogen monoxide = water.
  • Second is a patient with an avulsed eye from a possible explosion.
  • Third patient presented with an open mandibular fracture and signs of traumatic asphyxia.
  • At about 4 minutes, a fourth patient presented.  He was yelling and deaf.  He had signs of bilateral perforated tympanic membranes, or eardrums.  He was yelling that his neck hurt.
  • At about five minutes three more patients walked in with burning eyes from being maced.  
Sounds easy right?  Well in twelve minutes it is a very stressful and high paced incident.  

Treatments they were looking for:
  • Scene control
  • Assessments for every patient
  • V-fib arrest patient is to be defibrillated into a PEA
  • After PEA is present they expected you to determine hyperkalemic cause and administer sodium bicarbonate and/pr calcium chloride.  
  • The eye avulsion only required BLS care
  • The traumatic asphyxia required a cricothyrotomy within five minutes.  
  • Obtain SAMPLE history from deaf guy by writing it down
  • Flush the eyes of the maced individuals
  • DON'T OPEN THE BLACK BOX
If you opened the box, you became exposed to chlorine gas and had to flush your eyes before you could do anymore treatments.  I am not going to go into the details of how every team performed or what exactly we did.  All I am going to say is WE WON.  

That's right, Lee County EMS, my team, got first place this year.  So bragging rights are ours for the year, and then we will return for the competition once again.  There are many other similar competitions to this throughout the country and I will be on EMS Educast this month to talk about them a little more.  

So I am back and will be getting back to posting more often.  You may have noticed the new look of the site.  Tell me what you think.  I am hoping to make the move soon to FIRE-EMS Blogs.  

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