48. OBJECTIVES:
1. Why using Evidence Based Medicine is important
2. How to interpret 12 lead ECG’s under pressure
3. Proper use of the BVM
4. How to make and use push-dose epinephrine
5. To discuss medical mistake making
6. Pitfalls and pearls in transcuataneous pacing
7. Using the Plethysmography wave
8. Stability is a spectrum
9. Use of medications in cardiac arrest (narcan, bicarb and D50)
10. Use of diuretics in CHF
Notes de l'éditeur
HAVE FUN….TALK SLOW…… Intro
Experiment…let me know if you liked it, or did not like it.
Not my ideas EMCRIT / LITFL / Social media
To examine the evidence for and against commonly used EMS medications, paradigms and practices. To share with you what I have learned…the hard way/
I’m guilty
Was not taught. Is there data that shows this is good? Backboards, MAST pants, Therapeutic hypothermia, Epi? Should make you question every practice
Patients will die and some of them should. We need to be okay with this. Story about first arrest save…christian scientist in field…not up to me, not doing anyone any favors. You do not have to work every patient without a DNR. ASHLEY SHREVES – podcsts Talk to the family…stop asking DO THEY WANT EVERYTHING DONE!!!! USE THE WORD DEAD OR DIED. BE HONEST Its hard and uncomfortable. MISCARRIAGE STORY-----run around at office, with RAD tech, with MD….sent home…30 seconds….not viable.
Danse Macabre Michael Wolgemutin
Treat it. It is not our job to figure out who is a drug seeker… Common sense applies, but err towards overtreating vital signs=/= pain. Normal vitals is not a rule out Drug seeker vs drug seeker with pain? Probably both Won’t screw up assesment –CT scan
Won’t turn them in to an addict
2mg of morphine + severe pain = severe pain.
https://www.ncbi.nlm.nih.gov/pubmed/20926627
https://www.researchgate.net/publication/40821492_Are_vital_signs_valid_indicators_for_the_assessment_of_pain_in_postoperative_cardiac_surgery_ICU_adults
The ECG vortex. How to actually read a 12 lead in front of a patient
How to actually read a 12 lead in front of a patient. Prioritize
Majority of 12 leads are unremarkable
Not the problem
Up or down
Major things that need to be addressed
Most taken for granted thing. Got my ass kicked in the OR Positive pressure ventilations = decreased blood flow hyperventilation = decreased cerebral blood flow
Watch it like a hawk or most advanced person does it
The myth of 12-20. blowing off too much co2…slow their breathing Why are the pts breathing so fast? Herniation, DKA, acidosis, hypoxia?
PERI INTUBATION ARREST
Switch to PPV – decreased venous return If RSI Drugs like versed removal of pain stimulus = removal of catecholamines
Especially important in head injury - hypoxia or hypotension = death
Fluids ready, vasopresors ready and perhaps started…MAKE PSUH DOSE!
Works for many things fast and easy
You were taught a false dichotomy, ACLS sits on a throne of lies
“OH…I will pace them….” Pacing is not as easy as we make it out to be… EPI vs pacing are EQUAL AV association with EPI….AV DISSocaition with pacing = 25% loss (ATRIAL KICK)
Sick patient,
Sick patient,
Decompensated to this, pacing attempted
HOW DO we tell Pacing is working..ETCo2 and pleth wave
Uses for pleth Check spo2 do I have a pulse is it different in both arms----high aortic dissection Pacing PVC’s – perfusing? Hypovolemia - pulsus paradoxus PEA vs pulse
Not in the H’s and T’s Can not help
Can hurt…especially when you mix in 5mg of epi no benefit post arrest people (1 minute of arrest vs 20) keep them intubated?
What about dextrose? “It’s in the H’s and T’s”
The administration of dextrose during in-hospital cardiac arrest is associated with increased mortality and neurologic morbidity, journal of critical care. Stop slamming D5O just because…..WHAT IF THEY ARE HYPOGLYCEMIC? (next slide)
TENG studyIn our sensitivity analysis of patients with a downtime between 5 and 10 minutes, we found that dextrose was associated with an increased chance of ROSC (RR 1.06, 95% CI 1.01-1.10, P = 0.008), a strong trend toward decreased chance of survival (RR 0.83, 95% CI 0.68-1.01, P = 0.06), and decreased chance of good neurological outcome (RR 0.78, 95% CI 0.62-0.99, P = 0.04).
SEPTIC PT in DOCTORS OFFICE….SUGAR OF 20….TALKING….DIDN’T FIX ANYTHING
Of the 8 patients assessed as hypoglycemic by fingerstick blood analysis, only 3 had a low blood glucose on laboratory analysis of venous blood; of the other 5 patients incorrectly categorized by fingerstick blood analysis, 2 were actually normoglycemic and 3 were hyperglycemic. F
Accuracy of fingerstick glucose determination in patients receiving CPR. 1994 Southern medical journal
Seems to be persistent in EMS
Need to increase ventilations..guess where the CO2 goes otherwise…but hyperventilation is bad too increasing intracellular acidosis Decreasing oxygen offloading
“Bicarbonate may compromise CPP by reducing systemic vascular resistance.283 It can create extracellular alkalosis that will shift the oxyhemoglobin saturation curve and inhibit oxygen release. It can produce hypernatremia and therefore hyperosmolarity. It produces excess CO2, which freely diffuses into myocardial and cerebral cells and may paradoxically contribute to intracellular acidosis.284 It can exacerbate central venous acidosis and may inactivate simultaneously administered catecholamines.”
Bicarb and hyperkalemia? NO. There is no evidence and no mechanism….unless acidotic, but that doesn’t work either
Types Cardiogenic shock chronic heart failure
ACUTE HEART FAILURE LASIX IS A PRE_LOAD REDUCER
BUT INCREASES in MAP, SVR, plasma renin activity, and plasma norepinephrine levels.6 Essentially, furosemide led to activation of the neurohormonal system instead of turning it off.
There is initial increase in afterload with reduced stroke volume and cardiac output following furosemide administration due to increased catecholamines, renin activity and vasopressin.
SCAPE- too much afterload and too much preload Stress response guy with cannula off- hypoxia—worse pump function [Not talking about the pt who misses their dose….just the EMS SICK patient] Pneumonia (made that mistake) and hypokalemia!!!
Hoffman JR and Reynolds S showed that patients who got furosemide and or morphine for APE had more complications.5 However, the study was small (n = 57) and had multiple treatment arms.
Francis GS et al. described how administration of furosemide actually led to decreased LV function, increased LV filling pressures, increases in MAP, SVR, plasma renin activity, and plasma norepinephrine levels.6 Essentially, furosemide led to activation of the neurohormonal system instead of turning it off.
Kraus PA et al. demonstrated that PCWP was increased for the first 20 minutes after administration of furosemide.7
Finally, Marik PE et al. summarizes the evidence. Furosemide decreases GFR, activates the renin-angiotensin-aldosterone system, decreases cardiac output, and increases afterload early after administration.8
Think: Nitrates oxygen positve pressure elevate….The only EMS patients who should get lasix are those who missed their doses.
Probably not the truth, but there are a lot of mistakes made. Medical error-the third leading cause of death in the US.
Makary MA1, Daniel M2. (BMJ may 2016)
http://scienceblogs.com/insolence/2016/05/16/do-medical-errors-really-kill-a-quarter-of-a-million-people-a-year-in-the-us/
Mistakes I have made:
Decompress pacer/ missed femur fx / spleen refusal / GSW to head just culture - safety culture…..human error happens. Be okay with it and support the people who make the errors.
Be a skeptic….ask questions…do no harm as best as you can….learn from your mistakes
