http://podcasts.aanet.org/ems/ems_feb1512b.mp3

Really excellent review of abdominal injury and trauma from Albany Medical Center.

http://media.blubrry.com/emcrit/traffic.libsyn.com/emcrit/PreHRM_-_Minh_Interviews_Cliff_Reid.mp3

A great new prehospital podcast.

Enjoy!

Clearly, one of the greatest threats to remaining on top of your game as a quality prehospital caregiver is that of complacency. It is just too easy to settle in to a brand of medicine that feels really comfortable and stay there. Sadly, and certainly unfortunately for your patients, it won’t be long until you are providing, at best, average patient care. Soon to follow, if you don’t get with the program, you will cease to be part of the solution and instead will become part of the problem for patients unfortunate enough to call 9-1-1 on the day that you are on duty.

Read the rest….

http://www.emsworld.com/article/10611568/if-you-arent-reading-youre-rusting

The Hudson Valley Septic Shock protocols (as well as all the HV hypovolemia protocols) call for the titration of fluid (and pressors) to a systolic BP of greater than 90 mmhg. Many progressive systems are now using MAP as the target number. For example , Albany REMO calls for maintaining a MAP of >65 rather than chasing a systolic of >90 and this is how it’s done in the ICU as well. The truth is that this is a much better measure as the brain, kidneys and other vital organs need a MAP of 60-70 in order to remain perfused and the systolic alone will not give you that info. For example, a BP of 100/40 has a MAP of 60 while a BP of 88/60 has a MAP of 69 – in the first case the SBP is >90 yet the brain is not being perfused properly while in the second case MAP is 69, even though SBP is only 88.

Capnography is another useful parameter to keep an eye in shock states. Studies have shown that ETCO2 correlates well with Cardiac Output. It is not unusual to have ETCO2 in the 10s and 20s in severe shock states – very useful as monitoring tool to watch for sudden downturn in patient status.

I did not know this…

· If the Tibial Tuberosity CANNOT be palpated the insertion site is two finger widths below the Patella (and then) medial along the flat aspect of the Tibia. (The Tibial Tuberosity can be difficult or impossible to palpate on younger patients, As patients mature the Tibial Tuberosity becomes easier to identify.)

· If the Tibial Tuberosity CAN be palpated the insertion site is one finger width below the Tuberosity (and then) medial along the flat aspect of the Tibia.

Post quoted from theemtspot.com

With that thought in mind, how important should it be to keep the saline we infuse into our patients whom we want to keep warm at something close to body temperature? I hadn’t really given the question much thought until I got an email from Scott.

Scott’s one of those SWAT medic types. He works with his local SWAT team to provide on site medical interventions if the need arises. Scott had an interesting experience with an accidental infusion of ice cold saline. I’ll let Scott take it from here:

“I am on a tactical medic team.  The temperatures here have dropped recently (as they always do this time of year). We recently had a call out. Most all of our medics have an entry bag that stays in their vehicle and a main bag that stays in the response vehicle. As you can imagine, neither of these are heated or cooled, “temperature controlled” environments.”

“On this call out, we had an officer who was walking through the neighbors yard to provide perimeter security when he obtained a fairly significant laceration on his lateral right leg. As most officers would, he brushed it off, vowing to deal with it after the incident. After about 45 mins he finally called for a medic. We replaced him with another officer and escorted him back to the command post. “

“The officers leg from the laceration down was soaked with blood, pant leg, sock, everything. This officer was being particularly hard headed and said he would go get it looked at in the morning and asked us to simply bandage it for him. My partner was able to talk him into an IV because of the blood loss. I was focused on bandaging his leg while my partner started a 500 cc normal saline bag. I left to go back to the perimeter after finishing with the bandage and my partner stayed back to monitor him and finish his IV. “

“I was at the perimeter for all of 20 minutes when I was called back to the command post for assistance. When I got back the officer was lethargic, his extremities were cold to the touch his teeth were chattering, and he was slightly confused. “

“My first thought after, “Oh shit!” was shock, but I had a brief moment of sanity before the panic set in. I took my partners glove off and told him to grab the IV bag. As you guessed it was freezing cold to the touch. He had put the officer into hypothermia by giving him a sub-zero fluid bolus. “

“We quickly called for a unit, covered him up, took vitals and proceeded through our hypothermia protocols. “

“It had not even occurred to my partner that his IV equipment has been in his freezing cold trunk all night, and even when the patient went down hill, he didn’t see the obvious signs of hypothermia. In treating this officers laceration he nearly caused a more serious medical emergency. “

“Most agencies keep their trucks in a climate controlled bay or have a solution to heat their units or bags. However there are some that don’t. I thought this might be worth sharing with you. “

Thanks for the story Scott. And yes, it is worth sharing. I’ve mentioned before the importance of keeping trauma patients warm. As winter sets in here in Colorado, I can imagine all kinds of scenarios where this mistake could play a significant role in the patients outcome. Our medic units use warming plates for our IV bags, but the one in the kit remains unheated.

I also consider how many times I’ve started IV’s on the side of the road in a snow back or deep in the back-country. IV bags get left outside on special events and coverage situations like the one Scott describes here all the time. The next time you’re outside in the cold or pulling an IV bag out of a kit, don’t forget to feel that solution. Induced hypothermia does have its applications, but most of our patients will benefit from warm fluid

Human blood temperature is 38 degrees C or 100.4 degrees F – and average blood volume is 6 liters – it would follow then that infusing a liter of saline that is even at room temperature (72F) could lower body temperature somewhat. Infusing saline that’s even cooler than that could have adverse effects especially on sick patients. Something to think about especially now as the weather gets colder..…

Of course you are always better off using a Broslow Tape to estimate a pediatric patient’s weight, but when faced a quick decision on pediatric dosing, two quicks tricks that I found come in handy.

Method 1.  Weight= 8kg + 2kg for every year of age (eg. 1 = 10kg , 2 = 12kg) etc.

Method 2. Weight = Age + 4 x 2 (eg. 1 Year =   5×2 =10kg)

MAD Nasal Drug Delivery Device

The anatomy of the nasal mucosa allows for rapid drug absorption, and its location allows drugs to be delivered directly into the bloodstream and bypass the blood-brain barrier, all without the need for establishing IV access. Bypassing the blood-brain barrier allows many drugs to more rapidly benefit the patient by speeding their action on the central nervous system. This is particularly beneficial when administering benzodiazepines for patients experiencing seizures.

Drugs that can be administered intranasaly

• Ativan (lorazepam)
• Versed (midazolam)
• Naracan (naloxone)
• Glucagon (double dose – IM more effective)
• fentanyl
• (Epi has been studied successfully in dogs)

Some important administration points:

• Dosages are generally the same as IM dosages  
• Use as highly concentrated a form of the drug as possible
• Limit the fluid volume delivered to a nostril to 1 mL or less
• Divide the total amount of fluid to be delivered evenly between both nostrils
• Atomizers may have "dead space" within them and should be flushed with saline to deliver all of the medication OR just draw up an additional 0.12 ml of your drug and push the whole thing (that 0.12 will be left in the device)
• Allow 15 minutes before administering subsequent intranasal doses.

More info:

http://intranasal.net/overview/default.htm

http://www.medscape.com/viewarticle/726524

EMS World – Intranasal Drug Administration

Steps of Laryngoscopy

Steps of Laryngoscopy from Scott from EMCrit on Vimeo.

This is a great demonstration of proper laryngoscopy. Although he uses a video scope, pay attention to the first half where he discusses proper head placement and the correct sniffing position, something sorely lacking in most paramedic classes and practice. A good amount of prehospital failure is due to improper positioning.

Very thorough review of diabetes and DKA from the FDNY OMA.

Download here: http://db.tt/oaJ3TWrc

Also see previous post –  Pediatric DKA