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

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

Also see previous post –  Pediatric DKA  

Great lecture: Prehospital Sepsis by Luke Duncan, MD, Albany Medical Center

• Audio Link
  Video Link

Some pearls…

Identifying sepsis early is a key component of good outcomes

Simply saying the word “sepsis”or “septic” on your report will get the patient proper care an hour earlier!

He talks a lot about MAP – that being the new criteria for monitoring BP – much more accurate indicator – needs to be kept above 65 in order to perfuse the brain. Below 60 other end organs are affected as well. Systolic and/or diastolic may not indicate how sick the patient really is. MAP is where its at…(You can find this measurement on the Lifepak 12 /15 in bottom corner of NIBP area)

SIRS criteria for sepsis (Systemic inflammatory response syndrome)

• Tachycardia >90
• Tachypnea >20
• Temp <97°F or >100°F
• ^ White Count (Notice no BP measure here)

SIRS can be diagnosed when two or more of these criteria are present. When SIRS is due to an infection, it is considered sepsis. Noninfectious causes of SIRS include trauma, burns, pancreatitis, ischemia, and hemorrhage

Albany REMO has a great suspected sepsis protocol which uses MAP as one of the criteria. See protocol here – Lots of fluids early on, 2 liters in the field before considering pressors.

Key Points:

• Early identification saves an hour or more
• Early resuscitation saves lives
• Early antibiotics saves lives (Seattle is experimenting with paramedic administered antibiotics)

See this very interesting article: Wheezing in the Pediatric Patient

Some points that I found interesting:

· Regarding RSV: “Increased morbidity and mortality occurs in high-risk patients, including those younger than 6 weeks old, and those with a history of premature birth, hypoxia, congenital heart disease, chronic lung disease or immune deficiency.”

· “While corticosteroids are commonly used in the treatment of moderate to severe asthma, their use in bronchiolitis is limited. They are not considered a standard of care for the management of bronchiolitis (although they are used), and are not recommended for use in previously healthy infants with RSV”

· I found the same information in another Pediatric Emergency textbook; in that book it states that steroids are not indicated at all in the management of bronchiolitis.

· On another note, both the American Academy of Pediatrics and the PALS textbook mention the use of nebulized epinephrine for bronchiolitis. The AAP states that bronchiolitis may be more responsive to nebulized Epi over albuterol (which may be of limited efficacy in bronchiolitis)

· Regarding Asthma: Onset of action for ipratropium can be delayed for up to 60 minutes, however, “despite the delayed onset of action, studies have shown that the use of albuterol with ipratropium is more effective in reversing bronchoconstriction than using albuterol alone.”

I’ve read many opinions over time about which EKG leads we should be monitoring and I’d concluded that my best 3 to monitor are II, aVL & aVF as the 3 that give the best all around picture of what’s going on. I’ve seen many medics that have their lifepak 12 set to monitor II, III and aVF which basically only gives you an inferior wall view, probably not a good thing to work with a blind spot like this. Along comes this article in JEMS and now I think I may have found the elusive perfect lead. Although it’s been around quite a while, its use in the prehospital setting seems to be virtually unheard of. I quote the important stuff below:

A New Lead
The modified lead MCL-1 (originally called CL1) was introduced in 1968 – To run this lead, you keep the limb leads RA and LA in their standard position and place the LL electrode on the V1 position (the fourth intercostal space just at the right sternal border.) Select lead III on the monitor, and you’re now viewing lead MCL-1.

This configuration of leads gives a clear chest for cardioversion and defibrillation, and chest auscultation will also be easy. Lead MCL-1 closely resembles V1, so it offers many diagnostic advantages over lead II:

• MCL-1 is the best lead for differentiating V-tach from SVT with bundle branch blocks.
• You can immediately tell right from left ventricular ectopy.
• In most cases, right and left BBB can be recognized.
• Sometimes, P waves can be seen better.
• See the rest here

I have a Philips MRx 12 Lead monitor and the 3 lead cable has a 5th cable marked V. This allows me to monitor any V lead including v4r if I’m so inclined

I came across this great article focusing on ECG differences seen with pediatric patients. This is quite important to really know as something as simple as a normal PR interval for an adult could signify a AV block in a child.

Electrocardiogram (ECG) interpretation usually is taught in courses that focus on adults. For those who work in pediatrics, identifying appropriate parameters for infants and children is important. This article focuses on the differences between an adult and child’s ECG, differences in common arrhythmias (also called dysrhythmias), and unique treatment approaches to arrhythmias in children.

See complete article here: http://findarticles.com/p/articles/mi_m0FSZ/is_3_27/ai_n18612073/

This chart sums some of it up:

Posted by Unit 122

http://www.wgrz.com/news/local/story.aspx?storyid=79101&catid=37

Very interesting, I had someone this week who was .17, and the cop vehemently disallowed an on scene assessment in favor of rushing the patient to the station to do the breathalyzer so he could nail him on the DWI.

The call was an MVA with a significant MOI involved, and the officer was clearly wrong from a medical standpoint – the front end of the car was obliterated, and a full C-spine was called for. This law makes sense beyond the obvious legal ramifications since it gives medics leverage over any other responding entity who has interests other than patient care in mind. A simple blood draw can ensure that the law-enforcement side of things are covered, and we can then focus on patient care having taken care of the BAC issue.

However, I believe that this would need to be approved by the agency Medical Director, since REMAC protocols only currently indicate blood drawing on standing orders by Cyanide/Smoke Inhalation before Hydroxocobalamin (yes, that was a test question). The GOP states that any other blood drawing would be a discretionary decision made by the agency Medical Director.

Posted with WordPress for BlackBerry.

One last reminder before our finals!

Good luck!

Never forget:
1) SIFO (medical): Scene size up. Initial assessment. Focused Assessment. Ongoing Assessment.
Or
SIFDO (trauma): Scene size up. Initial assessment. Focused Assessment. Detailed assessment. Ongoing Assessment.

2) ABC DEFG (airway, breathing, circulation, disabilities, extremities, full vitals, GO).

3) IPASSO (inspect, palpate, auscultat, stabilize, seal, O2).

4) OPQRSTI (onset, provocations, quality, radiation, severity, time, interventions).

5) SAMPLE (signs/symptoms, allergies, medications, past hx, last intake, events).

6) Pertinent questions regarding call: eg. weight, LMP, PARA, Gravada, drug consumption, Etoh, smoking, etc.

Detailed Exam:* Head to toe assessment *Pay close attention to JVD, Ascites, Pedal Edema.

By Miguel

"This is why people fail exams and/or lose their certifications"

Rule #1: BLS before ALS.

Rule #2: Treat your patient not the monitor.

Rule #3: An ‘excellent’ EMT = a ‘good’ medic.

Rule #4: Protocols are guidelines, not set in stone.

Rule #5: Refrain from getting tunnel vision.

Never forget:

1) ABC DEFG (airway, breathing, circulation, disabilities, extremities, full vitals, GO).

2) IPASSO (inspect, palpate, auscultate, stabilize, seal, O2).

3) OPQRSTI (onset, provocations, quality, radiation, severity, time, interventions).

4) SAMPLE (signs/symptoms, allergies, medications, past hx, last intake, events).

5) Pertinent questions regarding call: ex: weight, LMP, PARA, Gravada, drug consumption, Etoh, smoking, etc.

* Head to toe assessment *

** approximately 40 questions before you begin ALS, unless the call is obvious **

Rookie Mistakes:

#1 Uses monitor for everything.

#2 Every call becomes ALS.

#3 Every chest pain is cardiac.

#4 Every patient gets an IV.

** don’t go by what the EMT’s tell you **

***Become a Clinician***