Greg Friese from EMS Educast invited me to guest cohost on episode 67.  On the show was David Page from the St. Paul EMS Academy.

Make sure to go check it out.

Thanks for stopping by,

Adam Thompson, EMT-P

Chronicles of EMS, A Seat at the Table takes on CPR effectiveness.  The Las Vegas video that they mention can be found below as well.  Keep up the good work Justin and Mark!

Side note - ILCOR, The International Liaison Committee On Resuscitation has not found any supporting evidence for the Autopulse.  They are the ones whom do the research for AHA.  Also, transporting patients without a pulse should be re-looked at by any agency performing this practice.  The initial treatment at the ER will not differ from the treatment we provide at the scene per ACLS guidelines.  Why not give the patient the best chance possible.  If they don't get a pulse back on scene, it is probably never going to come back--that's just the facts.

1. Rate & Rhythm
2. Axis determination
3. Complex, wave, and segment durations
4. Morphology
5. STE-Mimics
6. Ischemia, Injury, Infarct

In the popular and acclaimed JEMS article Experts Debate Paramedic Intubation, there were a few key points made that I would like to elaborate on, as well as provide some of my own insight from the research I have come across.


Key Point 1

Experience should be maintained in a number of manors:

• Operating room rotations
• Mannequin scenarios (without the dummy supine on a table)
• Cadavers if possible

Dr. Bledsoe: Are the alternative airway devices (e.g., King LT, etc.) good enough for prehospital airway management?

Mr. Gandy: Yes. The studies have shown that excellent ventilation can be achieved with these devices.

Key Point 3

The #1 way to confirm proper placement of the endotracheal tube in the field is end-tidal CO2 (ETCO2).  If you have ETCO2 available in the field, use it.  

ETCO2 measures the amount of CO2 that is being exhaled by the patient.  This lets us know that the O2 we are putting into the body is being used and exchanged for the CO2 that comes out via pulmonary perfusion.  This exchange occurs in the lungs, which just so happens to be the place that we are attempting to ventilate.

Key Point 4

Anticipate the difficult airway.

Mr. Gandy: The biggest problem is inadequate training and practice in airway evaluation, such as using the Malampatti or Cormack-Lehane criteria; using aids to intubation, such as bougies; the BURP maneuver; alternative laryngoscope techniques, such as the “skyhook” technique; and a good assortment of alternative airway devices, including either GlideScope or AirTraq. Ventilation should be emphasized over intubation, and extensive practice with BVM ventilation should be required.

Malampatti scoring is done by having the patient stick out their tongue.  The difficulty of the proceeding ETI attempt can be gauged by the visibility of the oropharynx.





Cormack-Lehane Citeria is utilized with direct laryngoscopy.  This is done by visualizing the vocal cords and making note of how much of the opening is visible:

• Grade 1, visualization of the entire laryngeal aperture; 
• Grade 2, visualization of parts of the laryngeal aperture or the arytenoids; 
• Grade 3, visualization of only the epiglottis; and 
• Grade 4, visualization of only the soft palate.

BURP Maneuver - Backward, Upward, Rightward, Pressure of the larynx.


Don't worry if you don't understand the picture above.  It is just a step by step of the BURP maneuver.  Basically you place your fingers on the palpable cricoid ring of the patient.  Push towards their posterior, and slightly towards their right.  This should bring the trachea and it's structures to the best point of view during direct laryngoscopy.


"Skyhook" - I believe Gandy is referring to what my peers and I call the "fish hook" maneuver.  This is reserved for the more hefty patients that may be hard to intubate.

This is a two person procedure.  One person is dedicated to laryngocopy, and the other will direct person 1, visualize the vocal cords, and pass the ET tube.

Person 1 - With Laryngoscope and a Macintosh blade

- Straddle the supine patient
- Hook the blade into the mouth
- Pull back, keeping the blade off of the teeth
- Make adjustments based off person 2's direction

Person 2 - With appropriately sized ET Tube

- Position yourself at patient's head
- Direct person 2 until the vocal cords are visible
- Pass ET tube


I spoke about the Glidescope in my post Video Laryngocopy.  Go check it out.


Key Point 5

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.


Points to remember:

• O2 & fluids for compensatory tachycardia
•  Synchronized cardioversion is the SAFER option
• If QRS is wide treat as V-tach

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

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

• Oral: Pediatric 6 - 10 mg/kg
• Intramuscular: 3 - 8 mg/kg
• Intravenous: Pediatric 0.5 - 2 mg/kg, Adult 1 - 4.5 mg/kg

I posted this article over at http://www.lifeunderthelights.com/ a few days ago and I thought it would good for here as well. I'm sorry that I've only rarely posted here, but I read this blog quite often and recommend it to all of my peers. Enjoy

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A few years ago I responded to a structure fire on the main engine out of my station. The fire was at a house that had been converted to a dog kennel and grooming shop just a few blocks away from the firehouse and was a short response time. It was a light-staffing day and we responded as a three person engine company. As the senior firefighter I was the acting company officer and my new girlfriend at the time, who just happens to be my wife now, was the backseat firefighter. Get ready for the “Awwww” moment… it was our first fire “as a couple”. There was a number of cool things that came out of the fire, but one of them was the fact that Gina grabbed *my* maul.

On our main engine, there’s an 8-pound maul (big hammer) that I grab as my tool of choice every time I jump off the truck for a fire. It just tucks so neatly in my SCBA’s belt and is so compact yet handy that I make a beeline for it every time. This time, Gina had taken it, so I grabbed a pick-head axe.

It’s amazing when I have my maul how every access problem looks like something that I can solve by whacking it with a hammer of some sort. On this fire, I learned that when one has an axe, every problem looks like it can be solved by some sort of chopping.

Moral of the story, Gina and I entered the structure, saved the pooches, and stopped the fire in its trucks with minimal damage. There’s actually a hilarious video that I believe is still on our department’s web site that I’d let you see if I didn’t hide the name of the department(s) I work for due to reasons of wanting to remain employed.

And, like a lot of posts I write, I told you that so I could tell you this about an EMS call I responded to an indeterminate amount of time ago. I have the honor and privilege to be the senior medic on most shifts I work and I precept a lot of students on the ambulance. This shift was no different and this 0-dark-30 call illustrates a point that I’d like to explain to you.

For this call, the primary ambulance out of our station responded because they were on the way back from another call and my partner and I responded in our ambulance because we were up on the alternating call rotation. They arrived at the poorly-accessible apartment complex a few minutes before we did and made first patient contact. As it turns out, the middle age patient had ran out of his/her prescription Lasix (a potent diuretic, or water pill) a week or so prior to the call and had been retaining a great deal of excess bodily fluid. The patient’s legs were markedly and grossly swollen and weeping fluid out of fluid filled blisters. The Patient called us because he/she could no longer stand the pain of the cellulitis (infection) that had developed. The patient had no respiratory compromise, his/her lungs were clear, and he/she really had no other complaints. The patient had an extensive medical history of organ failure and disease. He/she was fully alert and oriented, and was able to assist us as we simply picked him/her up and carried him/her to the cot.

As we were loading the patient up in the ambulance and I was about to get into the back to continue my assessment and treatment of the patient, the EMT from the other ambulance who happens to be an almost-done Paramedic student told me, “So those legs are the worst I’ve ever seen fluid wise, you’re going to push some lasix on this one”. I mumbled something and got into the truck. I was tired and wasn’t really able to form complete sentences at the time due to sleep deprivation. I continued my assessment where I found that the frail patient had a blood pressure in the 70 systolic range (Low!) and that in addition to retaining fluid in his/her legs, he/she was also retaining fluid in his/her abdomen and was probably in need of a paracentesis. I managed the patient with a (beautifully executed, I must say) IV stick into an impossibly small and crooked vein, and gave just enough fluid to bring his/her BP up a bit without adding to his/her fluid overload all that much. I put the Pt on oxygen and a cardiac monitor, which revealed a normal sinus rhythm without ectopy and obtained a 12-lead EKG as well, which was not indicative of any acute problems. The patient stated that his/her pain was managed by padding and positioning of his/her swollen legs and even though he/she complained of no breathing problems, I put him/her on a bit of oxygen via nasal cannula.

The transport was uneventful, although his/her blood pressure never did come up. The ER later diagnosed the Pt with complete liver failure and toxicity.

But the interesting part of the story is this, when I got back the medic student asked me about giving IV lasix to the patient, as we carry that in our medication stock and have it available as an emergency diuretic for patients in congestive heart failure and/or fluid overload with pulmonary edema and respiratory compromise. He was almost taken aback when I said that I didn’t give any.

I asked him if he did a full assessment. He said that he had tried… but that he didn’t have enough time before I arrived and we took the patient out to the ambulance. I gave him my assessment findings and the news of the very low blood pressure. He said that he agreed with me on not giving the lasix with the markedly low blood pressure but was curious when I explained that it wasn’t the reason I didn’t give the medication.

We in EMS, and especially new providers carry our own hammers… our treatments and medications that we’re able to give in the field. Medics that use these treatments more often are called “aggressive” and it is a badge of honor. In fact, in some cases, aggressive field treatment is indeed warranted and improves patient outcomes. However, in a lot of cases it is not indicated and patients benefit from what we don’t do more so than from what we could have done.

This patient didn’t have any respiratory compromise and while he/she obviously could have benefited from the dieresis or removal of the excess fluid, she didn’t meet the criteria for emergent field administration of lasix, which is respiratory compromise from pulmonary edema. I made the decision to let the physician evaluate the patient and determine the best treatment path that would fit in with the patient’s ultimate plan of care. I didn’t believe that the patient would ultimately benefit from my administration of lasix twenty minutes earlier than the ER could have done it if the physician so chose.

Every treatment we administer must be given with a full assessment of the risks and benefits to the patient for doing so. Every EMS person should familiarize themselves with the long-term care paths of the conditions we treat and try to maximize the long-term benefit to the patient with the acute and short-term care we give. Not every problem is “a nail” and sometimes the hammers we carry aren’t the best ultimate solution for excellent patient care. Remembering how we as EMS people fit into the grand scheme of the overall healthcare system and in the ultimate care paths of our patients will help us all to do what we’re supposed to do, which is to provide excellent and appropriate patient care.

It is also of note, I guess, that Gina rarely steals my maul anymore. Now that we’re married… I “give it freely” to her.. What’s mine is her’s, as they say.

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The original post has some pictures of the fire and of the doggies that my wife and I saved on our first "Fire Date" - It can be seen HERE

There are many causes of syncope. Syncope is the medical term for fainting. Most of us are pretty familiar with the common vasovagal cause. Fortunately syncope is often self-correcting; the patient hypo-perfuses, they blackout and fall, their body perfuses better, they wake up. This post will be dedicated to 12-lead presentations that may indicate causes of syncope.

I have decided to use some exerts from my favorite emergency physician/presenter, Dr. Amal Mattu.  Dr. Mattu has spoke and written on these topics multiple times.