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ateup25 wrote:This pt is suffering from cardiac tamponade. This can be seen from the JVD, and narrowing pulse pressures. This pt needs a pericardiocentesis, he may also need more extensive surgery such as a pericardiectomy when he gets to the hospital. Pre-hospital I would provide suportive care including high-flow O2, to try and reduce cardiac workload. Depending on the system maybe beta-blockers also.
Peridardiectomy is the cutting of a "Window" in the pericardium. This pt has probably bought one unless they are seen in a non trauma facility. The cause of the injury is penetrating so the Trauma gurus will explore and repair what is bleeding.
As far as beta Blockers, You will probably kill the Pt. The intial treatment is fluid resesatation and Dysrythmia control. With the BP that Thursday gave MS4 will probably be very bad for them and crash the BP to PEA. I was taught that a 2mg-5mg dose in an adult will drop the Systolic pressure by 10. Do not know how accurate that is since i never paid attention to it. I would be very cautious and use MS4 under med direction only. ateup what level of training do you have? You gave it a shot, do not let some of us get you down for trying.
"If you cannot accomplish great things, Accomplish small things in a great way"
I am an NREMT-P and an RN although I don't work as one. I will be the first to admit that the beta-blocker thing is out there and non-traditional although I had a med-command doc discuss it with me once. No one is getting me down Forums like this are for exchanging idea's and learning.
ateup25 wrote:I am an NREMT-P and an RN although I don't work as one. I will be the first to admit that the beta-blocker thing is out there and non-traditional although I had a med-command doc discuss it with me once. No one is getting me down Forums like this are for exchanging idea's and learning.
Ok that makes sense it was th RN side that would have killed the Pt :D .
"If you cannot accomplish great things, Accomplish small things in a great way"
I'm coming in late here, but a question, if I may..
As vital signs decline, would you utilize MAST pants? And if VS are lost, would a tube thoracotomy be indicated, and is that something that combat medics can perform in the field?
Just as a side note. I have had the fortune and misfortune of dealing with cardiac tamponade a few times in the field. The first tamponade patient came at me from left field about a month after starting work as a paramedic.
It was about 17 - 18 years ago. He was a middle aged dude sitting in a chair stating he wasn't feeling well and was a little short of breath. There was no recent trauma, or outstanding medical history that he made us aware of. He was alert and oriented and looked good. I remember thinking at first that is was another bullshit call.
I took his BP and low and behold, couldn't get one. Hell, the dude didn't have a radial pulse either! So now I was like, "WTF!?, no trauma, no medical history, and no freaking pulse, but he's talking to me with no real issues!" So, while my partner was trying to get a BP and make up for my apparent onset of being a dumbass with a BP cuff, I patched him up to the monitor and put him on oxygen.
He still was oriented and looking good. Well shit, now not only are myself and my partner screwed up because we can't get a BP on this dude and we're clueless, but the monitor is sucking too! The complexes on the screen and print out are looking super small and tiny. Great, no BP, radial pulses, and the monitor is taking a shit by showing little midget complexes!
Again he's still oriented, but saying he is a little short of breath. Well shit, now his face is all blue. This was before pulse oximeters were in the field, but the cap refill in his fingers wasn't looking great either, but still not too-too bad.
Fuck it, we loaded up and treated him with extra gas pedal and speed to the hospital. The doc sunk the needle in his chest as we walked in the door, and he was miracled back to feeling better after a boat load of blood was removed from around his heart.
I learned some things from this. There is always going to be medical issues that throw you a curve ball. However, they will have a rational explanation. Trust yourself and your gear. We both took the pulses and blood pressures and we both doubted the results. We were right, but got too locked into other things. The monitor looked jacked up, but was dead nuts on. Apparently the blood around the heart caused the complexes do appear smaller on our EKG. I haven't seen that again, but will be ready if I ever do.
Lastly, with regard to the deal about paramedics diagnosing. When I went through school many years ago, we were taught that medics don't diagnose. Bullshit! This isn't the old days when medics just opened a particular colored box when a doctor told them, and dumped whatever was in it into the patient. The whole diagnose/don't diagnose deal is a legal issue set up by EMS agencies trying to avoid liabilty issues.
Well, if you don't diagnose, then you can't treat. So if you are treating then you diagnose. Before starting down the contracting route overseas, the way I/we were handling the issue was a differential diagnosis. Basically saying you have narrowed the issue down to a few different possibilities, and are following the most likley problem. It's still seems like lawyer legal BS.
The bottom line is treat your patient with quality care. If you don't know something, or what is going on admit it and ask for help. And cover your ass with good documentation!
Well, enough rambling. RLTW!
Regt HQ '93 - '94
Bco 3/75 '94 - '96
Afghanistan '04 - '05
Iraq '05 - '08
Sudan '08 - '09
Iraq '09 - As soon as I can finish up my contract!
MAST trousers like anything else have their own indications and counter indications. I did a search and there are a ton of pages on em. I've never used them, but the consensus at the school house seems to be that they are the shit when used properly. "They" also say that most people who dont like them are not up on how to use them properly.
I'll bet one of the real medics here will be by shortly to give you a better answer then this.
Chest tubes are more of something youd do back at the aid station or somewhere setup for it. Its not shit youre gonna have in your aid bag nor would you wanna do a chest tube in a dirty(non sterile) environment. If the PT has a pneumothorax you can do a needle drill to buy time. If he has a hemothorax just use positive pressure ventilations til you can tube em.
As far as doing a chest tube on a dead patient.. well.. Why? Chest tubes are put in to drain air or blood from the plural space. On top of that it takes around 3-4 minutes or so to get the tube in place and about 5-6 minutes to have it in place and secured. Thats if you have the kits set up already. Thats a long time for a pt to be without o2.
hrmm.. maybe if they were in respiratory arrest due to a pneumo or hemothorax.
MAST pants, or "instruments of the devil" as they are referred to by our local agencies, can be extremely effective, when used properly and in the right circumstances.
I don't have a lot of time to talk about them, but basically, if someone needs mast pants, they are going to be in pretty bad shape ( unless you use them as a splint for something like lower tib/fib fx, which works well but takes a while to get set up ).
I only know of one time that MAST pants were used succesfully, and even in that situation, the patient ultimately ended up dying. One of the Lt's on the FD where I work was accidently run over by the Engine. The engineer quickly realized what happened, and smartly didn't pull the engine off of him, as it would have killed him in minutes. He was still conscious and alert, although in a lot of pain. They ended up putting the MAST pants on him, which gave him enough time for his family to come in and say their good byes.
Realistically, MAST pants are good when there is going to be a prolonged extrication, where you can set up and get ready to use them while the FD extricates the pt. But, you will run into a lot of people that will swear never to use them, just like they swear never to use the KED. It is a good idea to keep an open mind about using anything and everything you have available to you for patient care. If you swear never to use it, they why bother to keep it on your ambulance/ in your ruck?
Phulano wrote:MAST trousers like anything else have their own indications and counter indications. I did a search and there are a ton of pages on em. I've never used them, but the consensus at the school house seems to be that they are the shit when used properly. "They" also say that most people who dont like them are not up on how to use them properly.
I'll bet one of the real medics here will be by shortly to give you a better answer then this.
Chest tubes are more of something youd do back at the aid station or somewhere setup for it. Its not shit youre gonna have in your aid bag nor would you wanna do a chest tube in a dirty(non sterile) environment. If the PT has a pneumothorax you can do a needle drill to buy time. If he has a hemothorax just use positive pressure ventilations til you can tube em.
As far as doing a chest tube on a dead patient.. well.. Why? Chest tubes are put in to drain air or blood from the plural space. On top of that it takes around 3-4 minutes or so to get the tube in place and about 5-6 minutes to have it in place and secured. Thats if you have the kits set up already. Thats a long time for a pt to be without o2.
hrmm.. maybe if they were in respiratory arrest due to a pneumo or hemothorax.
Thursday wrote:MAST pants, or "instruments of the devil" as they are referred to by our local agencies, can be extremely effective, when used properly and in the right circumstances.
I don't have a lot of time to talk about them, but basically, if someone needs mast pants, they are going to be in pretty bad shape ( unless you use them as a splint for something like lower tib/fib fx, which works well but takes a while to get set up ).
I only know of one time that MAST pants were used succesfully, and even in that situation, the patient ultimately ended up dying. One of the Lt's on the FD where I work was accidently run over by the Engine. The engineer quickly realized what happened, and smartly didn't pull the engine off of him, as it would have killed him in minutes. He was still conscious and alert, although in a lot of pain. They ended up putting the MAST pants on him, which gave him enough time for his family to come in and say their good byes.
Realistically, MAST pants are good when there is going to be a prolonged extrication, where you can set up and get ready to use them while the FD extricates the pt. But, you will run into a lot of people that will swear never to use them, just like they swear never to use the KED. It is a good idea to keep an open mind about using anything and everything you have available to you for patient care. If you swear never to use it, they why bother to keep it on your ambulance/ in your ruck?
Before our area was able to set up a Life Support District and raise funds for a BSL ambulance to be housed with our local rescue squad, the response time for an ambulance or life flight helicopter was 45-60 minutes or greater. We've used MAST pants successfully on several gunshot victims when we had that long wait time. All the victims had gunshot wounds to the thorax and survived. I know they are not used as frequently as they once were, but was curious if they (MAST) are currently employed in combat situations or if the medics felt they'd be indicated in the original senario of cardiac tamponade.
As for "doing a chest tube on a dead patient". I wouldn't be attempting the procedure as it's beyond my scope of practice (EMT-D). (Refering to the original senario presented) the patient did not present with 'injuries incompatable with life', so hasn't been declared dead, just because their vitals tanked. (I acknowledge, in a multicasualty setting, the triage code for this patient may be changed from Red to Black and you'd move on to another patient). I'm aware it's not something generally done in the field, but inquired if it would be indicated for this patient, and wondered if this is something that would be attempted in a combat situation where sometimes extraordinary measures are taken to sustain life. Also, assuming you are not a lone rescuer and an assistant is bagging or administering O2.
Phulano wrote:MAST trousers like anything else have their own indications and counter indications. I did a search and there are a ton of pages on em. I've never used them, but the consensus at the school house seems to be that they are the shit when used properly. "They" also say that most people who dont like them are not up on how to use them properly.
I'll bet one of the real medics here will be by shortly to give you a better answer then this.
Chest tubes are more of something youd do back at the aid station or somewhere setup for it. Its not shit youre gonna have in your aid bag nor would you wanna do a chest tube in a dirty(non sterile) environment. If the PT has a pneumothorax you can do a needle drill to buy time. If he has a hemothorax just use positive pressure ventilations til you can tube em.
As far as doing a chest tube on a dead patient.. well.. Why? Chest tubes are put in to drain air or blood from the plural space. On top of that it takes around 3-4 minutes or so to get the tube in place and about 5-6 minutes to have it in place and secured. Thats if you have the kits set up already. Thats a long time for a pt to be without o2.
hrmm.. maybe if they were in respiratory arrest due to a pneumo or hemothorax.
We used MAST trousers a lot years ago. I really liked them and never had a problem with them. The indications for using them were more liberal than they are now.
One of the biggest bitches with them was that the hospital folks didn't know how to take them off very well, which resulted in expensive MAST pants being cut by uneductaed hospital workers. Another problem was with cleaning. They would really soak up the blood and I imagine in todays world of BSI precuations there would be some major issues.
All in all, I think they are well worth their cost and the time to put them on.
Regt HQ '93 - '94
Bco 3/75 '94 - '96
Afghanistan '04 - '05
Iraq '05 - '08
Sudan '08 - '09
Iraq '09 - As soon as I can finish up my contract!
Fish wrote:As far as EMS diagnosing I say bullshit I worked in EMS for many years and now have work as a PA. I treat patients that are having signs and symptoms in an acute settingl. After ordering rad, labs, or whatever else I need, I get those back and then I formulate a diagnosis with all the information that I have before me. Paramedics are good at impressions. How can you diagnose a NSTEMI from UA in an Ambulance? You can't. Alot of systems still only use 3 lead EKGs, what can you diagnose with that? How do you diagnose a PE in the field?
After reading this a few days ago and really thinking about it I have to agree with Ranger Fish. Diagnosing pre-hospital is impossible. All a medic can do is treat the S/S that the pt. presents with. If you have a pt. that presents with all the classic S/S of a MI and there is no ST elevation on a 3 lead or a 12 lead what do you do. You talk them into the ride to a ER and treat it as an MI with MOAN or whatever your SO and protocol allow.
Case in point I had a Diabetic female with NSTEMI that I would have never keyed in on had she not gone to the hospital with us. I was having a bad night and was pissed that we were on an illness at 0200 when I should be sleeping. She had no S/S of an MI just did not feel right and all vitals were WNL untill transfer of care to ER staff. Never had a EKG change through the whole episode that I know of. If I would have signed her off she would have died. I would rather be way off base and expect the worse than fuck up and have someone die. Someday I might go to PA or Med school, untill then I will leave the diagnosing to those with good malpractice insurance and play it safe.
As for the PE, I will take a bashing for this probably, but, the SPO2 monitor is as close as you can get to determine a difference between Hyperventilating and PE. If sats are low I would determine where the closest facility is and move. If not I would monitor the pt. and see if the condition could be improved on scene. In any case I would try to transport the pt. to an ER. All in all pre hospital providers treat the S/S but cannot diagnose or we would not have a signoff chart to write with a pt. signature saying they refused care.
MAST Pants are a thing of the past. We carry them because the state says they have to be on every ambulance but use them for splinting only. When I started in this field before joining the Military we used them for their intended purpose and I cannot recall a pt. living that they were used on. As far a for a pelvic fx, they are too cumbersome and time comsuming with the new splinting devices out there. I would have too look for them on the truck if I had to use them and then clean the dust off. That being said they still teach them and the PHTLS class is pushing for their return as a standard of care. In a rural setting they could be benificial and lifesaving. Trauma is a surgical disease that you fight the clock from the begining and the MAST might buy the pt an extra 10-15 min to the OR. However impoperly used they can kill the pt. and i have yet to see any great research that says they work more than not.
"If you cannot accomplish great things, Accomplish small things in a great way"
