Confusing airway question..

[colorado207]

9. What would be the correct sequence of treatment for a 76 year old female with a pulse of 142. The patient is also cyanotic around the lips and nail beds?

Your Answer: Ventilate her with a BVM and transport

Incorrect

Correct Answer is: Continue assessing en route to the hospital and apply high flow O2

Thanks for any info.

I had almost the exact same question.. plus tripod-ing. I thought BVM too. my instructor reminded me that some COPD Pts are constantly cyanotic! (which I have actually seen!) I guess It's more about tidal volume and RR. (But damn! that pulse rate is pretty high!)

 

[colorado207]

Your instructor's not looking at the big picture. This can be a VERY important thing to know come airway management time.

I was under the impression that last oral intake was really important for the OR... :unsure: !

 

[usalsfyre]

I was under the impression that last oral intake was really important for the OR... :unsure: !

Maybe...but unless the patient becomes somehow unconscious anesthesia is gonna ask again anyway.

 

[jwk]

Maybe...but unless the patient becomes somehow unconscious anesthesia is gonna ask again anyway.

I'll ask, and assume the patient has a full stomach regardless of what they tell me. However, if they tell me they had two Big Macs on the way to the ER (happens all the time) I'll believe them.

 

[usalsfyre]

I'll ask, and assume the patient has a full stomach regardless of what they tell me. However, if they tell me they had two Big Macs on the way to the ER (happens all the time) I'll believe them.

Certainly the best way of operating.

 

[AMF]

The highest flow of O2 is via BVM, you know

 

[njemtbvol]

The highest flow of O2 is via BVM, you know

true, but somehow granny isn't going to like it when you're forcefully squeezing air down her throat when she's got adequate tidal volume..

 

[jwk]

The highest flow of O2 is via BVM, you know

Or do you mean highest FiO2?

 

[DesertMedic66]

I was under the impression that last oral intake was really important for the OR... :unsure: !

Be very careful saying "oral intake". You might get more info then you want. :huh: It's happened soo many times to us we just say ate and had to drink.

 

[colorado207]

haha what!?
:huh:


I can already tell, I'm going to get addicted to this forum.

 

[Jay]

Colorado... "Last oral intake" is from your SAMPLE questions, it is the "L" and is basically the last time the patient had something to eat or drink, I usually ask "What time did you last have something to eat or drink?", if it sounds like a "meal" then I add "Any snacks? Any alcoholic beverages? Soda? Water? or anything else?", interesting thing is I never got asked once by the patient or their family why I am asking the way that I do. Even with the other questions you should probe enough to get a solid understanding for your report, e.g. "Have you taken any medications either Rx or OTC? Herbs? Drugs...etc." for meds and even with allergies, "are you allergic to any medications? foods? pollen, grass? or anything else?"... You will learn that probing can mean answers, for example what if they are allergic to shellfish and ate it 20 minutes ago but probing unveiled the answers that you were looking for.

Now onto the meat and potatoes of this post... If the Pt is in tachycardia, the odds of them being hypoxic are more than just fair because the heart will not have adequate time to pump and refill causing a decrease in effective circulation and thus hypoxia. It is true that ALS can administer drugs such as lidocaine or amiodarone or cardiocert but if the patient can tolerate the ride to the ER and you can advise the ER of the pending arrival and if it is within protocol than transport! I definitely could not condone bagging because first of all we don't know the Resps/Min. Secondly the hypoxia is caused by the cardiac condition which could be a million different things so a NRB would be the way to go. If you could check the SpO2 before the NRB is applied and afterwards I would be fairly certain that you would see the SpO2 is 94 or below and may rise steadily on high flow O2. It shouldn't drop. Also, is the patient conscious? Would they even tolerate the bagging? Always play it safe and try to think the questions through to uncover the best answer.

 

[colorado207]

Colorado... "Last oral intake" is from your SAMPLE questions, it is the "L" and is basically the last time the patient had something to eat or drink, I usually ask "What time did you last have something to eat or drink?", if it sounds like a "meal" then I add "Any snacks? Any alcoholic beverages? Soda? Water? or anything else?", interesting thing is I never got asked once by the patient or their family why I am asking the way that I do.

Oh yep I know that. But there's a debate over how often the question is needed and/or useful. Other than diabetic and food allergy emergencies, the only reason I could assume that it would be a question often asked (especially in trauma Hx), is for anesthesiologist in the OR (should surgery become necessary.) Or perhaps knowing how much or how likely that person is to vomit.
Do you really always get so in depth with your LOI line of questioning? Or are you referring to cases where you suspect that you really need to know more about LOI from some other indicator?

 

[hippocratical]

"Last oral intake" is from your SAMPLE questions, it is the "L" and is basically the last time the patient had something to eat or drink...

I gotta ask on this one, because it's been bugging me -> Ages ago I did a Wilderness FA course where they advised that "L" should be "Last ins and outs"... So anything eaten/drunk + defecation + (here's a good one) Menstruation.

Got a female Pt? Has abdominal pain and spotting? Allegedly not pregnant?
Q: "When was your last period?"
A: "oh yeah, it's been about 4 months but that cant be it..."

Anyone else advise "L" being this?

 

[colorado207]

I gotta ask on this one, because it's been bugging me -> Ages ago I did a Wilderness FA course where they advised that "L" should be "Last ins and outs"... So anything eaten/drunk + defecation + (here's a good one) Menstruation.

Got a female Pt? Has abdominal pain and spotting? Allegedly not pregnant?
Q: "When was your last period?"
A: "oh yeah, it's been about 4 months but that cant be it..."

Anyone else advise "L" being this?

ooohhh cool. yeah that is waaayyy better than simply last oral intake. (Maybe they just didn;t want a bunch of basics running around asking insignificant MOI trauma patients when was the last time they had a BM.^_^
hehe.) But yeah that is a way better use for the 'L'. Thanks!

 

[MrBrown]

The idea behind the L was last oral intake and was supposed to be of importance for the Anaesthetist.

Now, do any of Brown's friends who are Senior Registrars or Consultants in anaesthesia actually care? No.

 

[Akulahawk]

The idea behind the L was last oral intake and was supposed to be of importance for the Anaesthetist.

Now, do any of Brown's friends who are Senior Registrars or Consultants in anaesthesia actually care? No.

They'll just assume that the patient just ate a huge meal and chased it with lots o'fluid and take the appropriate precautions to prevent aspiration during induction to anesthesia. Thus... they don't actually care much.

If that patient has been NPO for the past 12-24 hours... all the nicer for the anesthetist.

 

[Handsome Robb]

It is true that ALS can administer drugs such as lidocaine or amiodarone or cardiocert but if the patient can tolerate the ride to the ER and you can advise the ER of the pending arrival and if it is within protocol than transport!.

Sinus tachycardia with no ectopy and no severe hypertension isn't going to get any drugs or cardioversion.

 

[Akulahawk]

Sinus tachycardia with no ectopy and no severe hypertension isn't going to get any drugs or cardioversion.

I pretty much second this. Sinus Tach w/o ectopy and the patient appears to be compensating/tolerating this well... I'm just going to sit back, relax and give the patient a nice quiet ride. As soon as the patient needs tx... I'll give it. otherwise...

 

[Jay]

Oh yep I know that. But there's a debate over how often the question is needed and/or useful. Other than diabetic and food allergy emergencies, the only reason I could assume that it would be a question often asked (especially in trauma Hx), is for anesthesiologist in the OR (should surgery become necessary.) Or perhaps knowing how much or how likely that person is to vomit.
Do you really always get so in depth with your LOI line of questioning? Or are you referring to cases where you suspect that you really need to know more about LOI from some other indicator?

You should question everyone in depth but take control of the Q&A so that their answers don't take all day. Regardless of the call, the rule of thumb for medical calls is: The more information, the better. You should get into the habit of formulating the way that you do your SAMPLE in the field so that you can rapid-fire and quickly gain vital information. Your SAMPLE for the EMT exam is another subject altogether. Trauma should be a faster evolution however information gathering is vital, this can be done en route with the stable patient. Just remember that symptoms can present differently and knowing how to ascertain the information can save your patients life.

How much field experience do you have? Just curious. Remember that everyone will develop a style based off of their individual field experience.

Now on that note, let's delve into Meds, if you ask if they have taken "Any medications including OTC's and herbs whether theirs or anyone else's or if they tad taken any illegal drugs or ETOH", this can rule out anaphylaxis in certain cases, it can be a precursor to find out if there are any contraindications such as sexual enhancement drugs and nitro, perhaps they got it from a friend... You may uncover a TCA OD or some other OD... etc. (which you normally have about one hour before they go down hill) All in all this type of questioning takes me 5 or 10 seconds to ask and about the same to get a good answer in most cases. You'd be surprised on what you will uncover. The most important precedent is to build a repertoire with your patient so that they know that your not an LEO and that their answers wont "get them in trouble".

I gotta ask on this one, because it's been bugging me -> Ages ago I did a Wilderness FA course where they advised that "L" should be "Last ins and outs"... So anything eaten/drunk + defecation + (here's a good one) Menstruation.

Got a female Pt? Has abdominal pain and spotting? Allegedly not pregnant?
Q: "When was your last period?"
A: "oh yeah, it's been about 4 months but that cant be it..."

Anyone else advise "L" being this?

Interesting. In Pennsylvania we are only required to inquire as to their last meal, beverages, etc. But I try to probe to see if there is any vomiting (or nausea for that matter) and every girl should be asked to see if pregnancy is an option if they are in the age ranging from puberty to menopause or anything in between. As far as menstruation, I know that we are professionals and we can pretty much ask anything as long as we present the question professionally but this one is new to me.