Disagreement on a scenario

[certguy]

Scenerio

Okay guys ,

2 questions .
1. How would TP increase intercranial pressure if there's no head trauma ?
2. What is MAP ?

 

[VentMedic]

Trendelenburg and an unsecured airway can also present problems. Even with a tube it can present problems.

 

[Ridryder911]

Okay guys ,

2 questions .
1. How would TP increase intracranial pressure if there's no head trauma ?
2. What is MAP ?

1. One does not have to have a head injury to raise intracranial pressure (ICP). Actually even sneezing could cause death, if it was not such a short duration of ICP. Raising the head to a 30 degree angle can drastically reduce ICP as well as placing the head lower than the body (TP) will increase it. (Ever hung upside down and feel the pressure?) It seems simplistic in which it is, but many never consider such basic things such as positioning.

2.Mean Arterial Pressure (MAP) is the average arterial pressure during a single cardiac cycle.
One can easily obtain the MAP by doing the formula (MAP= [(2 x diastolic)+systolic] / 3) and most ECG monitors have it already calculated on electronic BP cuffs.
MAP should be closely monitored and personally I rather know the MAP as I believe it is the fifth vital sign. Understanding the perfusion pressure, is just as important as the blood pressure itself.

R/r 911

 

[iamjeff171]

it is my understanding that you are also supposed to treat for shock based on MOI. the pt is also exhibiting some early signs of shock with skin that is cool to the touch. isnt a drop in BP a very late sign of shock and at that point the pt is already decompensating. we are taught to place pts with signs/symptoms of shock into TP. i was curious how you would explain the reasoning for not following your protocols in court when a pt dies. somehow i dont think "well there are some studies that show it may not help" will pass. or maybe it would. it just seems to me like you could get in a lot of legal trouble by not following protocols backed by lots of lawyers and medical professionals


-Jeff

 

[MSDeltaFlt]

Since we're talking about MAP's and ICP's, we're actually discussing Cerebral Perfusion Pressure (CPP). The Americal College of Surgeons teach in ATLS, PHTLS, and BTLS that the CPP=MAP-ICP. You need at least a CPP = 60mmHg to perfuse the brain. Even a transient decrease is dangerous. So, no Trendelenburg. You don't even stand on the breaks while enroute to the hospital.

Here's the reasoning (yes, we may have gotten off track, but here we go):

The pt in the scenario has a BP of 100/60. That gives us a MAP of 73. Normal ICP is 0-10. If your pt has a decrease in LOC with a drop in GCS of 2 or more points, you can easily have an ICP of 15-20 (this is a safe assumption since we don't place ICP monitors in the field).

Let's bring that formula back in. CPP=MAP-ICP. CPP=73-15=58. CPP=73-20=53. Even a transient decrease is dangerous. This means that the risk increased that our poor pt will be doing good, if he survives the stabbing, to relearn how to tie his shoes; let alone go to the bathroom by himself.

Food for thought. Stay safe.

 

[Flight-LP]

it is my understanding that you are also supposed to treat for shock based on MOI. the pt is also exhibiting some early signs of shock with skin that is cool to the touch. isnt a drop in BP a very late sign of shock and at that point the pt is already decompensating. we are taught to place pts with signs/symptoms of shock into TP. i was curious how you would explain the reasoning for not following your protocols in court when a pt dies. somehow i dont think "well there are some studies that show it may not help" will pass. or maybe it would. it just seems to me like you could get in a lot of legal trouble by not following protocols backed by lots of lawyers and medical professionals


-Jeff

The key here is having an actual understanding of WHY this occuring in a patient, not "this is what we are taught and what the protocols say". This is why EMT-B's are ineffective on a 911 ambulance, because they do not understand the concept, they just go off of what they are told. As others have stated, Trendelenburg does not work and will cause an increase in ICP. Think of basic physics, namely Newton's laws. An object (blood, air, any organ of mass, etc.) once in motion will remain in motion and follow the path of least resistance. Simply put, everything at the bottom of the patient will move up towards the head. The head is now supporting all of the weight from that mass. Don't you think that will increase some pressure on or in the head? That is 6th grade science stuff, if it still isn't understood, then you need to step away from EMS.....................

You shouldn't care what a piece of paper says. Don't be a cookbook EMT, do what is right for your patient and understand why it was right.................

Trendelenburg and an unsecured airway can also present problems. Even with a tube it can present problems

Great point................

Since we're talking about MAP's and ICP's, we're actually discussing Cerebral Perfusion Pressure (CPP). The Americal College of Surgeons teach in ATLS, PHTLS, and BTLS that the CPP=MAP-ICP. You need at least a CPP = 60mmHg to perfuse the brain. Even a transient decrease is dangerous. So, no Trendelenburg. You don't even stand on the breaks while enroute to the hospital.

Here's the reasoning (yes, we may have gotten off track, but here we go):

The pt in the scenario has a BP of 100/60. That gives us a MAP of 73. Normal ICP is 0-10. If your pt has a decrease in LOC with a drop in GCS of 2 or more points, you can easily have an ICP of 15-20 (this is a safe assumption since we don't place ICP monitors in the field).

Let's bring that formula back in. CPP=MAP-ICP. CPP=73-15=58. CPP=73-20=53. Even a transient decrease is dangerous. This means that the risk increased that our poor pt will be doing good, if he survives the stabbing, to relearn how to tie his shoes; let alone go to the bathroom by himself.

Food for thought. Stay safe.

Awesome response! You probably lost a couple of people, but this good info to remember........

 

[JPINFV]

it is my understanding that you are also supposed to treat for shock based on MOI. the pt is also exhibiting some early signs of shock with skin that is cool to the touch. isnt a drop in BP a very late sign of shock and at that point the pt is already decompensating. we are taught to place pts with signs/symptoms of shock into TP. i was curious how you would explain the reasoning for not following your protocols in court when a pt dies. somehow i dont think "well there are some studies that show it may not help" will pass. or maybe it would. it just seems to me like you could get in a lot of legal trouble by not following protocols backed by lots of lawyers and medical professionals


-Jeff

Well, I think you're assuming a lot by assuming a lot.

First, Trendelenburg is not in everyone's shock protocol. (Linky: http://www.ochealthinfo.com/docs/medical/ems/treatment_guidelines/t05.pdf Yes, it is the paramedic protocol, but, technically speaking, Orange County, CA doesn't have a written protocol for EMT-Basics to follow. If you need a protocol to tell you when you need to put a patient on oxygen then you probably shouldn't be on an ambulance in the first place).

Second, your assuming that a patient's blood pressure in a traumatic injury is supposed to be kept at 120. Let me ask you a question, which of the following is worse. Dumping a patient's hemocrit or hypoprofusion? Furthermore, along those lines, higher blood pressures can interfere with a patient's body's ability to control their own bleeding. Sure, it might not save them in the long run, but all the body has to do is survive till it reaches an operating room.

Third, while arguable geared more for paramedics than basics, you're assuming that protocols are a cookbook. (ex, Riverside, CA ALS protocol. First sentence: http://www.rivcoems.org/downloads/downloads_documents/Protocol102904/7000.pdf) A fairly large number of service's protocols start off with a statement that goes along the lines of calling treatment protocols a guide, not a recipe.

 

[iamjeff171]

first i will have to apologize for being a lowly emt student (last time i checked, this was the BLS forum)...

is it standard to tell ppl who question you to get out of ems and compare them to 6th graders???

If you read carefully, my post never doubted the ineffectiveness of trendelenburg or its effects on ICP. they taught me a good deal about newtons laws in engineering school, and i agree it is pretty basic. if im not mistaken trendelenburg is supposed to help compensate for shock based on these same principles; but that is beside the point and i understand studies show this doesnt actually help shock. I never once stated that his BP was a concern at the moment. My questions pertained to the legal aspect of being a basic and not performing an intervention (one of the few basics have at our disposal for shock) on a patient that fits the criteria. This is all based on the national registry, and i understand that different areas may not have trendelenburg in their protocols. my particular area does have it tho, as do many others i am sure.

i'll rephrase my question: lets say there is no als available. lets say you dont put this pt in TP, but you package, give him O2, control bleeding and transport/reassess. well, on the way to the ED the pt goes hypotensive and eventually dies. well now the family is unhappy and decided to sue. would an emt-b really have any leg to stand on legally for not performing an intervention on a pt that had no contraindications to it? i definitely dont advocate or want to be a "cookbook EMT", and this is a serious question about the legal aspects. hopefully someone will try to answer it without the flames. or maybe i should just quit asking questions and get out now

-Jeff

 

[MSDeltaFlt]

If you follow your protocols, then you have nothing to worry about. Someone could sue you all day long, but they won't get very far.

 

[Ridryder911]

The good thing about Basic is that since it is simplistic there is very little litigation against them except the inability to recognize wounds & injuries, and movement and transfer of patients.

The more you know the more they sue...

As well, don't just bank on protocols to C.Y.A. mine have always included ..." discretion and judgement of the Paramedic"... I personally will not work for one that has step by step procedures and direction. Protocols should be for guidance and suggestions only...

R/r 911

 

[Vanatta67]

ABC then immediate life threats.

 

[JPINFV]

ABC then immediate life threats.

Ok, this thread was on it's third page and has expanded into a side conversation regarding patient positioning and protocol issues. Even if your post was on page one, a generic answer like this does absolutely nothing to answer the original poster's question. Hell, "ABC then immediate life threats" is more generic than the answer for most medical scenarios in EMT-B classes (high flow O2, position of comfort, call paramedics, immediate transport).

 

[Vanatta67]

Ok, this thread was on it's third page and has expanded into a side conversation regarding patient positioning and protocol issues. Even if your post was on page one, a generic answer like this does absolutely nothing to answer the original poster's question. Hell, "ABC then immediate life threats" is more generic than the answer for most medical scenarios in EMT-B classes (high flow O2, position of comfort, call paramedics, immediate transport).

Was just posting but by the way nice job being a ****

 

[byun01]

I am going to have to disagree with a few of the people's responses, respectfully. As a former medic and currently a medical student, this "patient" who got stabbed will need surgery. Contrary to popular belief, a medic will do very little in helping this patient, besides an IV. An EMT-B's responsibility is to respond, package, and transport. ALS if available should be called for and intercepted. Nevertheless, you should never wait on scene for this type of patient. He or she needs a surgeon's knife, not a paramedic's IV.

 

[Vanatta67]

The golden hour!

 

[Flight-LP]

The "golden hour" is a myth.




















I figured since we are now keeping posts under 10 words, that this would sum it up. What do y'all think?

 

[Ridryder911]

I am going to have to disagree with a few of the people's responses, respectfully. As a former medic and currently a medical student, this "patient" who got stabbed will need surgery. Contrary to popular belief, a medic will do very little in helping this patient, besides an IV. An EMT-B's responsibility is to respond, package, and transport. ALS if available should be called for and intercepted. Nevertheless, you should never wait on scene for this type of patient. He or she needs a surgeon's knife, not a paramedic's IV.

Unfortunately, we have BLS services, and within that BLS EMT's. As well, IV's (alone) have never been proven to be beneficial for most trauma cases prehospital or even in a ER. Rather, as you described trauma is a surgical disease.

Fluid resuscitation has been demonstrated not to be effective, however; there is reasons for Paramedic care. In-depth assessment and clinical diagnosis to treat possible underlying cause, to recognize other potential and associated injuries on trauma (i.e. tension pneumo) and securement of airway with utilization of RSI as in TBI and those with increasing ICP. So in realistic and accurate treatment modality it is not the IV that is main reason the Paramedic is needed. It is the treatment that can be performed, by having that IV is why ALS is needed.

R/r 911

 

[EMTMandy]

Before it became too deep (since it is on a basic level) I was going to suggest to perform a better assessment, while enroute. Pressure systolic of 100 and really a mild tachycardia of 120's, I would be looking for another underlying cause of unresponsiveness. Since it does not appear to be compensated, at the time.

Yes...before this thread turned into the true monster of all monster threads (in which case, I should have been here before the wandering and insults DAYS ago haha) I'd like to take a minute to stress the importance of further assessment. Aside from obviously securing the airway, visible bleeding control and C-spine precautions for Thispatient, I'm a strong believer in Every patient getting at least a Primary assessment (which takes little to no time at all) and in this case, preferrably a rapid (RAPID) trauma assessment on scene before packaging. as Ridryder911 said, conducting a more thorough one en route after the rondezvous with necessary help is also a great idea. There could be in fact a Major underlying cause that would otherwise be stepped over if nothing else.

also-

To quote CERTGUY
"Has anyone thought to check for exit wounds ?"

Or any other serious wounds?

Back to the murky details of the ORIGINAL post...which seems miles away and buried from mine...

It never stated whether the patient was bleeding profusly from the visible wound or not. It also never stated the weather conditions. this may seem like a far reach but suppose it was cold outside so the bleeding was controlled until in the back of the rig. patient starts to warm up and bleed out not only from the visible wound, but an exit wound or any others that were missed.

As a very wise instructor of mine has always said--

"More is missed by not seeing than by not knowing"

 

[MSDeltaFlt]

Threads evolve.

 

[EMTMandy]

I am aware of that.